Skip to main content

Full text of "Textbook of abnormal psychology"

See other formats

From the collection of the 


v Jjibrary 

San Francisco, California 





Professor oj Psychology, Division Dean of Life Sciences, University of California 

Professor of Psychology, University of California Medical School, 

Los Angeles, California 


Dean of the U?,iversity, Professor of Psychology, Director of the Psychological 

Clinic, Johns Hopkins University. 
Chief Psychologist, Sheppard-Enoch Pratt Hospital, 'Towson, Maryland 






Made in the United States of America 

First Edition January, 1934 

Reprinted September, 1934 

Reprinted September, 1935 

Reprinted January, 1937 

Reprinted October, 1938 

Second Edition August, 1939 

Reprinted February, 1942 

Reprinted January, 1943 

Reprinted September, 1943 

Reprinted April, 1944 

Third Edition, 1945 

Reprinted March, 1946 

Reprinted August, 1946 

Reprinted January, 1948 

Fourth Edition August, 1950 





Without reflecting any discredit on the pioneer treatises on this topic, 
it can fairly be said that the present volume marks the beginning of an 
epoch. In fact, I am strongly inclined to believe that the volume sig- 
nalizes the beginning of the scientific era in abnormal psychology. The 
authors, it would appear, have produced a work which is in line with 
the foundations laid by Pierre Janet, and infused with the spirit of the 
great French pathologist. While the work of Janet has necessarily been 
restricted to the clinical aspects, the present authors have coordinated 
therewith the contributions of general and experimental psychology; 
thus producing a structure worthy of its foundation. 

I am impressed, in the first place, with the vast amount of materials 
collected in this volume. No other book has attempted such a task. 
Obviously, this is a sharp departure from the conventional type of psy- 
chology text, in which "easy steps for little feet" has become more and 
more the rule. In conjunction with the literature-references, which are 
of extraordinary definiteness, the book furnishes a starting point from 
which the really industrious student may branch out into any sub- 
topic in this complicated field. 

In the second place, I am impressed with the critical balance of the 
book. Giving the various isms and theories their places, the authors 
avoid imposing on the reader either isms or emotional anti-isms (which 
is more than I can say for my own writings). Without being subjected 
to the stress of violent iconoclasm, the reader is prepared for immunity 
to both pseudo-psychological novelties and ancient superstitions. 

There are various points of interpretation, of course, on which I 
should take issue with the authors; and on some of these points I should 
possibly be right. These features of the presentation, however, in- 
crease my appreciation of, and respect for, the whole. The authors, 
and the psychological profession are to be congratulated on this magnum 
opus, which demonstrates, among other things, that scientifically 
minded psychiatrists and psychologists can work together in harmony 
and fruitfulness: for, it should be said, this book has a history which is 
not superficially obvious; and in that history, Dr. Chapman has played a 
part of no small importance. 



This admirable book is written by two psychologists for students of 
psychology. It is a splendid work and to my mind the outstanding 
treatise on the subject today. It is obvious that to its preparation 
there must have been given long study and painstaking effort, yet one 
may easily forget this in the readability of the book. The authors have 
written simply and their presentation of theory and of fact is clear. 
There is in this volume a remarkable amount of information of great 
value to the student. 

I am not in agreement with the authors in some of their conclusions, 
but I do agree that the psychologist is not qualified to treat "func- 
tional" mental illnesses without the cooperation of the physician, 
either within or without the hospital. No worthy psychologist or psy- 
chiatrist would undertake the treatment of what might seem to be the 
mildest neurosis without thorough physical examination, the effort to 
define the possible organic factor. Such an examination having been 
made and negative findings recorded, the fact remains that one of the 
most common and swift recourses of the neurotic is to physical symp- 
tomatology. The psychologist cannot ignore or adequately weigh 
such symptoms. He is at a disadvantage. 

Granted that the psychiatrist has to act today too frequently on 
insufficient information both historical and clinical; granted that the 
psychologist may in many instances bring to patient and physician very 
great assistance, we pass into dangerous territory when we take mental 
disease out of the hands of the medical profession. The physician 
needs all the help he can get in this field. The professions which may 
contribute to his assistance are many. Nevertheless the directing 
force must be his. It must not be forgotten that mental illness presents 
the greatest of all problems in the fields of preventive medicine and the 
public health. 

I look upon these years of association with Dr. Dorcus and Dr. Shaffer 
with the greatest pleasure. If in some measure the opportunities af- 
forded by the hospital have contributed to the success which is their due 
in producing this book I am glad. They have also contributed much 
to our clinical work generally and to the treatment of our patients. 



The text books in Abnormal Psychology which have appeared in the 
last ten years are, on the whole, either restricted to a discussion of the 
purely functional disorders in which the organic aspects are ignored or 
else they tend to explain all mental abnormalities as having an organic 
origin. Although previous authors have recognized the inadequacy of 
either of these methods alone, the attempts at combining the two have 
not been highly successful. When attempts have been made, the textual 
material has been too elementary to allow for anything other than a very 
cursory and brief statement concerning a given topic. This procedure 
has been necessitated in many instances by the lack of preparation of the 
students who enter the courses and by the wide range of purposes for 
which the texts have been intended. 

The present writers have purposely ignored the problem of adapting 
the text to those students whose preparation in psychology and the re- 
lated sciences is inadequate. On the contrary, this text has been written 
to fill the needs of advanced students in Psychology, Pre-medical 
students and Medical students who desire more psychological informa- 
tion. The latter group should find that the material dovetails with 
their information on Physiology, Neurology and Psychiatry. We have 
also purposely introduced, wherever possible, scientific terminology 
rather than popular terminology, since we feel that the scientific terms 
will be encountered by the individual from time to time in daily life 
and that a course in Abnormal Psychology should familiarize students 
with these terms. 

The facts and principles of abnormal psychology have been presented 
by other texts almost entirely apart from the principles of normal 
psychology. In the present text, the authors have attempted to ap- 
proach the discussion of abnormal phenomena through consideration of 
the normal. The symptoms and behavior of the abnormal individuals 
are not seen as completely new or mysterious ways of reacting but are 
recognized as exaggerated manifestations of normal functioning. Thus, 
dissociations of the personality are viewed in the light of the various 
conceptions of normal integration; and the abnormalities in the attempts 
at satisfaction of desires are considered through an understanding of 
the normal functioning of desires. 



Our approach has followed along the lines of what has come to be 
known as reaction psychology. However, eclecticism has been utilized 
wherever it seemed helpful in the understanding of the phenomena under 
discussion. This procedure, however, has not involved the adoption 
of the variant systems of psychology from which particular viewpoints 
and terms have been drawn for expository purposes. 

In most texts, the obvious question as to what is to be done about 
the abnormalities discussed, seems to be left unanswered. Conse- 
quently we have attempted to set forth the major principles of psycho- 
therapy as they are practiced today. It is hoped that this material will 
not only be helpful to the Premedical and Medical students but will 
also indicate to the general student the principles which are applicable 
to the treatment of these conditions and enable them to adjust them- 
selves better to their environment. 

Baltimore, Maryland 


The basic organization of this textbook has been retained through 
four editions. It is the opinion of the authors that it follows closely 
the outline most frequently used for presenting the principles of normal 
psychology. The attention of the reader is directed first to abnormali- 
ties of the sensory and motor systems, then to disorders of central func- 
tions and finally to abnormalities as they are manifest in the total 

The present edition includes three new chapters: Brain Damage Dis- 
orders, Psychosomatic Disorders and The History of Mental Illness. 
In the first of those new chapters an effort has been made to tie together 
the sensory and motor disorders through the central nervous system. 
This chapter has, therefore, been given over primarily to topographical 
relationships. Although psychosomatic medicine and the history of 
the abnormalities were discussed in other editions, the present edition 
includes separate chapters for both of these topics. In addition to these 
new chapters, the section on psychotherapy has been rather completely 
rewritten and throughout the book the results of recent research have 
been added wherever they seemed most appropriate. Despite the fact 
that approximately 250 new references have been added, it is obvious 
that all of the source material available could not be included in a 
volume that is to remain useful as a textbook. Omission of a discussion 
of any particular research does not imply that the authors considered 
it unimportant, but merely that other material seemed to be more useful 
for this text. 

As a result of our own teaching experience and from suggestions made 
by our colleagues who have used the earlier editions, we have added a 
glossary and rearranged some of the material to obtain greater clarity 
for the student. It is the opinion of the authors that these additions, 
changes and reorganizations will increase the value of the book to the 
student and research worker in the field of abnormal psychology. 




The writers wish to acknowledge their indebtedness to the late Dr. 
Knight Dunlap of the University of California at Los Angeles, the late 
Dr. Ross McC. Chapman of the Sheppard and Enoch Pratt Hospital, 
and Dr. Frank R. Smith, Jr., of the Johns Hopkins Hospital for their 
criticisms and suggestions concerning various parts of the manuscript; 
to Dr. Lawrence F. Woolley of the Sheppard and Enoch Pratt Hospital 
for his aid in the sections on therapy; to Dr. Robert H. Peckham for 
preparing the majority of the drawings; to Dr. Vernon P. Scheidt for 
aid in compiling the first index; and to Miss Virginia Shaffer for her 
assistance in editing the manuscript. Since the book was first published, 
a number of our professional friends have pointed out errors that ap- 
peared unavoidably in the first edition and have made suggestions con- 
cerning the inclusion and deletion of certain materials. We wish to 
express our appreciation to these friends and to acknowledge especially 
the suggestions of Dr. Frank R. Pattie, Jr., of Rice Institute and Dr. 
Edward Girden of Brooklyn College. We wish also to express our 
appreciation to Dr. John S. Lawrence for reading and criticizing some 
of the material dealing with pain; and to Dr. James M. Rankin for 
writing the section in which a recapitulation of some of the psychoanaly- 
tic theories are made; and to Dr. Margaret Jones for assistance in prepar- 
ing the glossary and the table of contents; and to Mrs. Ethel Camarenba 
and Miss Mary Jane Beam for assistance in preparing the glossary and 
typing the manuscript material. 

Through the cooperation of St. Elizabeth's Hospital, The Training 
School of Vineland, and The Rosewood Training School, the photographs 
of epileptic, athetotic and feebleminded patients have been made 

To the following publishers who have given us permission to use and 
reproduce material from their books and journals, we owe our gratitude 
and take this means of expressing it. 

American Journal of Orthopsychiatry. Journal of Abnormal and Social Psychology. 

American Journal of Obstetrics and Gyne- Journal of Genetic Psychology. 

cology. Journal of Mental Science. 

Journal of Mental Hygiene. Lancet. 

Journal of General Psychology. Harper. 



Mental Measurement Monographs. University of Chicago Press. 

Psychological Bulletin. University of California Press. 

Psychiatric Bulletin. Charles Scribner's Sons. 

C. V. Mosby Company. Warwick and York, Incorporated. 
R. G. Badger Company. Houghton, Mifflin Company. 

D. Appleton Company. Macmillan Company. 
Ronald Press Company. w w NortQn c 
Lucas Brothers. , ~ ~ 
Dartmouth College Publications Longmans Green Company. 
Liveright Publishing Corporation. Oxford University Press. 

P. Blakiston's Sons Company. Williams & Wilkins Company. 
Social Science Research Council Publications. 




Self reference as a criterion of abnormality, i; Statistical determination as a 
criterion of abnormality, 2; Degree and Kind of responses as criteria of abnor- 
mality, 5; Social and individual harmfulness as criteria of abnormality, 7; Lack 
of appropriateness as a criterion of abnormality, 8; Habit formation and its 
relation to abnormal psychology, 9; Abnormal psychology and psychiatry, 10; 
Abnormal psychology and social psychology, u; Abnormal psychology and 
sociology, 13; Abnormal psychology and mental hygiene, 19; Abnormal psy- 
chology and neurology, 20; Abnormal psychology and psychosomatic medicine, 



Sensory defects: general considerations, 22; Ratio of sensory disorders in normal 
and abnormal people, 25; Terminology for sensory functions, 26; Visual dis- 
orders, 28; Auditory disorders, 48; Cutaneous disorders, 58; Disorders of the 
other senses: gustatory, olfactory, kinesthetic and vestibular senses, 72; Supple- 
mentary neurological bases of cutaneous disorders, 83; Compensation of the 
senses, 86; Synesthesia, 88. 



General aspects of normal muscular activity, 90; Motor disorders: abnormal 
reaction time, tremors, spasms, tics, convulsions, athetosis, myoclonus and 
chorea, 93; Motor disorders: paralysis, ataxia, hypertonia, atonia and hypotonia, 
101; Reflexes for clinical diagnosis, 105; Speech disorders, no; Disorders of 
acquirement, no; Handedness in relation to stammering and stuttering, 118; 
Physiological concomitants, 124; Theories, 126; Therapy for stammering and 
stuttering, 130; Lisping, paralytic speech, mutism, aphonia, echolalia and ver- 
bigeration, 133; Disorders of writing and gesture, 135; Disorders of elimination, 


SHIPS) 141 

Pathological agents in brain damage, 141; Localization of function: general 
problems, 142; Visual areas, 144; Auditory areas, 147; Somesthetic areas, 149; 
Motor areas, 150; Autonomic functions, 151; Frontal cortex, 152; Parieto-tem- 
poral areas, 155. 





Retardation of association, 158; Flight and incoherency of association, 160; 
Dearth and perservation of association, 162; Blocking of association, 165; Apha- 
sias, 165; Dyslexia, 168; Amnesias, 173. 



Integration, 184; Dissociation theory, 185; Redintegration theory, 192; Inatten- 
tion theory, 194; Conditioned reflex theory, 196; Psychoanalytic and instinctive 
theories, 204; Case summary, 226; The Adlerian approach, 228; The Jungian 
approach, 229; The psycho- analytic approach, 230; The psychobiologic school, 



Relation of the terms urge, drive and instinctive tendency to the term desire, 235; 
Modification of desires, 237; Alimentary desire, 240; Excretory desire, 249; Amo- 
rous and reproductive desires, 253; Parental desire, 265; Preeminence desire, 266; 
Desire for conformity, 268; Desire for activity, 268; Desire for rest, 270; Feelings 
and emotions, 273. 



Gastrointestinal disorders, 281; Respiratory disorders, 284; Cardiovascular dis- 
orders, 284; Skin disorders, 285; Disorders associated with arthritis and rheuma- 
tism, 286. 



Theories of sleep, 287; Chemical theory, 287; Physiological theories, 288; Bio- 
logical theories, 288; Psychological theories, 289; Neurological and histological 
theories, 289; Sleep norms and criteria of sleep, 290; Abnormalities of sleep, 292; 
Narcolepsy or somnolences, 294; Treatment of insomnia, 296; Dreams, 297; 
Hypnosis, 304; Methods of induction, 306; Prestige and non-prestige sugges- 
tions, 309; Susceptibility to non-prestige waking suggestions, 310; Susceptibility 
to prestige suggestions (hypnosis), 314; Personality of the hypnotist, 317; Stages 
of hypnosis, 318; Influence of hypnosis on physiological functions, 319; Influence 
of hypnosis on psychological functions, 322; Criteria of hypnosis, 330; Hypnotic 
regression, 332; Theories, 332. 



Introduction to classification and history, 337; Attention getting, 347; Identi- 
fication, 348; Compensation, 348; Rationalization, 349; Projection, 349; Insulation 
and timidity, 350; Negativism, 351; Regression, 351; Fantasy, 351; Repression, 


352; History, 354; Primitive, 354; Ancient, 355; Dark Ages, 358; Modern, 362; 
Classification, 366. 



Psychoses associated with exogenous toxins, 374; Alcoholic disorders, 374; Drug 
psychoses, 377; Gases and metals, 378; Disorders associated with infections, 379; 
Syphilis, 379; Encephalitis, 382; Cerebro spinal meningitis, 383; Chorea, 383; 
Circulatory or blood stream conditions, 384; Senile psychoses, 384; Psychoses with 
cerebral arteriosclerosis, 385; Traumatic psychoses, 386; Glandular disturbances, 
387; Epilepsies, 395. 



Etiology, 409; Schizophrenia, 414; Symptoms, 414; Types of schizophrenia, 416; 
Simple schizophrenic reaction, 416; Hebephrenic reaction, 425; Catatonic reac- 
tion, 427; Paranoid reaction, 430. 



Paranoia, 435; Manic-depressive psychoses, 441; Manic states, 445; Hypomania, 
446; Acute mania, 446; Hyperacute mania, 447; Depressed states, 448; Simple 
retardation, 448; Acute melancholia, 448; Depressive stupor, 449; Involutional 
melancholia, 455. 



Etiology, 459; Neurasthenia, 463; Anxiety states, 467; Psychasthenia, 470; 
Hysteria, 477; Theories of hysteria, 478; Etiology, 480; Symptoms and forms of 
hysteria, 480; Multiple personalities, 484. 



Nature and measurement of intelligence, 491; Mental deficiency, 501; Types of 
mental deficiency, 504; Cretinism, 504; Hydrocephalus, 505; Macrocephalus, 
506; Microcephalus, 506; Mongolism, 507; Amaurotic family idiocy, 510; Other 
types, 510; Etiology, 510; Social significance, 519; Improvement of the stock, 
520; Treatment and education, 523; Superior Intelligence, 524; Psychological 
deficit, 526; Emotional defective states, 528; Psychopathic states, 529. 



Metrazol, insulin and electric shock therapies, 534; Psychosurgery, 549; Narcosis 
therapy, 550; Benzedrine sulphate therapy, 554; Vitamin therapy, 554; Fever 
therapy, 556. 




Direct and non-direct therapy, 557; Primary psychotherapeutic techniques, 562; 
Psychoanalysis, 562; Distributive analysis and synthesis, 572; Psychotherapeutic 
devices, 575; Suggestion, 575; Hypnosis, 579; Hypnotherapy, 582; Hypnogogic 
reverie, 583; Oneirosis, 583; Indirect suggestion, 583; Persuasion, 588; Catharsis, 
590; Desensitization and reeducation, 594; Explanatory and interpretive therapy, 
603; Bibliotherapy, 604; Negative practice, 605; Special psychotherapies, 605; 
Psychodrama, 605; Group therapy, 607; Play and release therapy, 608; Psycho- 
therapeutic aids, 608; Occupational and recreational programs, 611; Psysio- 
therapy, 614; Basic habit training, 615; Changes in environmental factors, 616. 







In all of the treatises on abnormal psychology, there arises the prob- 
lem of determining what activities are normal and what activities are 
abnormal. The solution of the problem becomes imperative if abnor- 
mal psychologists hope to offer aid in the treatment of mental difficul- 
ties. The fact that no solution has been reached is due in a large meas- 
ure to our lack of knowledge of the normal individual. 

One conception of the norm of life is that often adopted by the phy- 
sician or psychologist, who takes his own life or some feature of his life 
as the norm or standard. If this norm is adopted, then that which 
agrees with it is normal; that which differs in any way is abnormal. 
That this procedure is fallacious and even dangerous is almost obvious 
to anyone possessing an elementary knowledge of individual psychology. 

The physician or psychologist is likely to have occasional attacks of 
indigestion, to forget from time to time many important engagements, 
to dream after eating a heavy dinner, to feel at some time that people 
are talking about him, or that he is a failure in life. These are ex- 
periences common to the abnormal individual and are often regarded 
as symptoms of abnormality. The physician or psychologist may ad- 
mit these symptoms in his own case but will interpret them as perfectly 
normal events, or he may not even think of them. It is only when one 
of these symptoms becomes exaggerated that the others begin to assume 
an important role in determining a norm. All that this method of 
approach accomplishes is the establishment of a multiplicity of norms. 

Let us assume then that abnormal psychology is concerned with the 
development of concepts and principles of unusual mental activity, 
with special emphasis placed upon the relation of these principles and 
concepts to general, child, and adult psychology. If this definition is 
accepted and if a separate field is postulated, let us now examine it and 
see what the field comprises. 

It has just been said that abnormal psychology is a study of unusual 
mental activity, and therefore, any psychological process or response 


that differs from the usual must be abnormal. How do we determine 
what is an unusual activity? 


One method involves a statistical determination for each form of 
mental activity or for each type of response, resulting in the establish- 
ment of norms or averages. Then, whenever a particular response fails 
to come within a definite range on either side of the average or mode for 
its type, it is to be rated as abnormal. The range selected must by 
necessity be arbitrary; consequently any interpretation based upon this 
method of determination must be arbitrary. In common parlance we 
speak of abnormally tall and abnormally short individuals. In either 
case the meaning of the term "abnormal" is the same, and the basis for 
our statement depends upon our judgment of height. Height lends 
itself accurately to measurement; and if a sufficiently great number of 
measurements are made, a reliable average can be obtained. That is, 
the prediction may be made that if another group of individuals of the 
same race, sex and age are measured, approximately the same range of 
heights will be obtained and approximately the same average. The 
distribution of heights presented in figure I will be useful for our dis- 
cussion. The average height is approximately 5 feet, 7 inches. At 
what point on the scale must an individual fall in order that he may be 
called "unusually" tall or "abnormally" tall? At what point may 
he be said to be "abnormally" short? If we arbitrarily select 5 feet, 
3 inches as unusually short and 6 feet as unusually tall, then our de- 
termination of abnormality becomes quite simple. Stature serves 
as a convenient illustration of our point, but is in itself of importance 
in determining the mental activity of the individual in so far as it may 
or may not indicate a dysfunction of one of the endocrine glands, which 
produces acromegaly, cretinism, and other diseases. Stature may also 
influence mental activity if the individual is socially sensitive con- 
cerning it. 

An examination of a distribution of intelligence tests scores (fig. 2) 
will be equally illuminating. An average score is obtained for the group; 
and individuals are classified as geniuses or feebleminded in accordance 
with the position that their scores indicate. The distribution of in- 
telligence scores in figure 2 does not in itself in any way indicate where 
the demarcation between normality and abnormality should be drawn 
This must be done arbitrarily. 


UNDER 63 63 

68 69 


72 & OVER 

FIG. I. Height of 304,113 accepted white recruits to the United States Army, 1906- 
15. Army Anthropometry and Medical Statistics. F. L. Hoffman. Report to Na- 
tional Academy of Science, Philadelphia, November 21, 1917. 

Fio. 1. Letter scores on Army Alpha Test, 94,004 drafted white men. Memoirs Na- 
tional Academy of Sciences, Vol. XV, p. 855, table 406. 


Intelligence is a psychological concept, whereas stature is a physical 
concept, but in the case of each the notion of abnormality is a statistical 

While we have stated that the norm is derived in part mathematically 
and in part arbitrarily, what we should say is that the average is math- 
ematically derived and serves as a basis for determining the range that 
is acceptable as normal. 

If we accept the average as the norm, then deviation from the average, 
beyond arbitrarily set limits, constitutes abnormality. A man above 
the average stature for his group is abnormal. A child above the aver- 
age for his group in intelligence, is abnormal. The upper limit does 
not have to be the same as the lower limit. We might, for example, 
decide that the limits are, for stature in the illustrative group, 5 inches 
above the average and 7 inches below the average. We might revise 
this, and set the limits of the normal range at 7 inches above and 5 
inches below. If there is no determinant of the norm, other than the 
average, we can decide upon any range we choose. If there is no good 
reason for adopting one range rather than any one of a great number 
possible, then the average would have no value. Obviously, we usually 
employ some other norm or standard, in addition to the average. This 
accessory standard may be described in terms of desirability and 
undesirability, beneficiality and harmfulness, appropriateness and in- 
appropriateness. We may incorporate these apparently divergent 
criteria under the terms: advantageous and disadvantageous. We may 
proceed further and say: that which is advantageous is normal and 
that which is disadvantageous is abnormal. This conception is adequate 
within the limits imposed in our subsequent treatment. If all mental 
functions were adaptable to statistical measurement, then the task of 
determining abnormal conditions would be somewhat simplified. Un- 
fortunately this is not true. 

A few examples of psychological functions that do not lend themselves 
to statistical interpretation are stammering, sex perversions, functional 
blindness, and loss of memory (amnesia). Any one of these conditions 
may be exaggerated to a marked degree or may show only a slight 
deviation from the norm. How badly does a person have to stammer 
in order to be classified as a stammerer? The question may appear 
foolish, but actually there are very few individuals who have never 
hesitated in their speech at some time or other. Most of these people 
are not to be classified as abnormal, and no arbitrary scale thus far 
devised is satisfactory for any of the above conditions. In regard to 


loss of memory or failure to recall (amnesia), the situation is almost as 
troublesome, although it should be possible on the basis of our present 
psychological knowledge to set up a useful scale for this type of deviation. 


There is another complicating factor in the establishment of suitable 
working norms; namely, that responses or activities may vary in kind 
and degree. These two aspects of activity may vary concomitantly 
or they may vary independently of each other. It is desirable to ex- 
amine this idea further since it will clarify some of the problems arising 
in the field of abnormal psychology. 

In considering that aspect of response which may be called degree, 
it may be found that a response is of the correct type for a given situ- 
ation but that it is inadequate since it is not proportionate to the 
stimulus. For example, the individual who applauds very boisterously 
and for a long time each comical situation at the theatre, is giving 
essentially the right type of response, but his reaction is exaggerated. 

The kind of response given in one situation may be inadequate in 
another. The inebriate in a swallow tail coat standing in the middle 
of the street directing traffic would not be making an inadequate or 
abnormal response under the circumstances. If, however, a clergyman 
or street cleaner, dressed in the garb of his occupation should do the 
same thing, his response would be abnormal or inadequate. Students 
celebrating a football game behave in a manner that would be inap- 
propriate for certain other occasions. Some of their other responses 
seem to need careful scrutiny, especially those connected with fraternity 
initiations. Their activities appear appropriate for the occasion upon 
superficial examination, but closer scrutiny reveals the fact that their 
actions resemble the actions of groups who have been swept by hysteria. 

The examples which have been discussed are also useful for illustrating 
certain other features of abnormal psychology. By definition, it was 
indicated that any unusual mental activity or response is abnormal. 
This has been interpreted to mean that only those responses which 
are undesirable belong in the sphere of our discussion. It is true that 
only undesirable activities give either the individual or society trouble, 
but trouble in itself is not an adequate criterion for deciding when a 
particular mental phenomenon is abnormal. An individual with an 
exceptionally keen memory, or one with tactual hypersensitivity, or an 
expert wine taster must be considered as belonging to an abnormal class 
of individuals. The abnormal psychologist must formulate theories 


and rules for the origin and development of geniuses as well as explain 
the genesis of personality disorders. In other words, the extremes or 
deviations from the average, regardless of whether above or below, are 
of some interest to our discussion. 

If suitable norms could be established for every psychological function 
and if a suitable conclusion could be reached concerning the deviations 
from these norms that are allowable for the socalled "sane" individual, 
there would be still other problems confronting us. Two individuals 
both of whom have had influenza accompanied by its customary toxie 
effects may be found to exhibit entirely different kinds of mental re- 
actions. For example: a depression with mental symptoms may occur 
in one case but not in the other. Two individuals may have been in 
the same automobile accident; nevertheless, only one of them happens 
to develop a phobia of riding in moving vehicles. These differences in 
human reactions must be accounted for in some way. They may be 
explained on a basis of the individual's past experience or they may be 
explained by constitutional differences, that is, the mental and physical 
make-up, as inherited. This line of reasoning indicates the importance 
of a sound inheritance as one of the main features of mental stability. 
An example of the relation of inheritance to the responses to normal 
environmental factors is furnished by the behavior of a particular strain 
of goats. If a sudden noise is made, they become paralyzed and cannot 
move. Other strains of these animals do not react in this manner. On 
a similar basis, the psychotic tendencies of the black, brown, yellow, red 
and white races might be predictable. There are, in fact, certain men- 
tal "racial" differences, but just how far these differences are influenced 
by environment and training and how far they are "strictly hereditary" 
cannot be ascertained, although such differences might be expected on a 
basis of heredity alone. 

The interrelation of heredity, biochemistry and environment can be 
demonstrated readily if we refer to work on some of the lower animals. 
It is possible to breed strains of rats that are very susceptible to noises 
that produce convulsive-like behavior. It is possible also to influence 
the frequency of the occurrence of these convulsive seizures by con- 
trolling the vitamin intake of the animals. Furthermore, the appear- 
ance of the convulsions will be determined in part by the type of 
surroundings in which the animals are placed. Thus it is evident that 
all of these factors act as a whole in determining the kind of response 
that the animal makes. 



An aspect of abnormal psychology that may appear somewhat puz- 
zling upon superficial examination is the relation between social harm- 
fulness and individual harmfulness. What is harmful or disadvanta- 
geous to the individual may also prove harmful or disadvantageous to 
the group. However, what is beneficial or advantageous to the in- 
dividual may prove harmful or disadvantageous to the group. Whether 
a beneficial or a harmful characteristic is abnormal for a given group is 
not always determined by the frequency of occurrence of the charac- 
teristic in the group. In reference to the preceding statements we may 
cite: (i) the child who masturbates and continues to play with the 
group; (2) the criminal who commits a holdup; (3) the prevalence of 
exopthalmic goitre in regions where there is a deficiency of iodine. In 
these regions there would be a high frequency of goitre which might be 
considered normal for that specific group, but abnormal for the popu- 
lation at large. 

Closer scrutiny reveals well organized tendencies with respect to our 
judgments concerning this matter. In general, any trait or any action 
of the individual will not be considered abnormal by the social group 
unless it proves to be an annoyance to the group. A man may possess 
an extraordinary fear of germs that will lead him to excessive hand 
washing, but society as a whole will pay little or no attention to the 
peculiarity since it does not interfere with the comfort or the activity 
of the other members of the group. Another individual may have a 
loss of sensation in his arm and no social attention will be given to his 
case. If an individual through perversion of his reasoning processes 
becomes a political paranoiac, and attempts to alter our political struc- 
ture, society will demand his incarceration. A speed maniac may be 
dealt with immediately in a rather drastic way. 

Activities that are not harmful to the personal well-being of the in- 
dividual or that are not injurious to society may go unnoticed for years. 
The individual who wears bizarre clothes or who wears his hair cut in 
an unusual fashion may have psychopathic tendencies; but as long as 
his actions do not become obnoxious he will not be interfered with, 
although he may be called eccentric. W 7 hen actions become harmful 
to the individual, they are usually considered abnormal. If an individual 
should attempt to starve himself to death, in all probability society 
would interfere. Attempts at suicide are dealt with by law. Suicide 
is disapproved of by society, not because it is harmful to the individual 


but because of social consequences. The religious taboo^of suicide 
probably grew out of the notion that life was the property of the tribe 
or state. 


Social approbation of actions determines to a considerable degree the 
classification of an individual as "normal" or "abnormal." We do not 
mean that social approbation itself is necessarily the determining factor, 
but that the person who cannot distinguish between what is socially 
approved and what is not, probably lacks in observation or in reasoning 
ability. Deficiency in one of these aspects is a primary basis for his 
"abnormal" behavior. We must not fail to recognize that actions which 
are disapproved of at one era and classified as abnormal, may at another 
era become the social fashion. Certainly women would have been 
accused of exhibitionism 20 or 30 years ago if they had appeared in 
public in the costumes which now meet social approval. Conversa- 
tion concerning sexual matters between members of the opposite sex, 
which is now condoned, would have been classified not many years ago, 
as an indication of degeneracy. 

Although we have presented a number of criteria that are used by 
various people for determining whether an individual is normal or 
abnormal, no one of the criteria is adequate alone in dealing with the 
borderline case. Those patients who manifest extreme behavior pat- 
terns could be classed as abnormal by any one of the criteria. Behavior 
is altered and passes by almost minute gradations from the normal or 
usual pattern to the abnormal or unusual pattern. It is in cases of the 
less extreme type, that we find it necessary to apply all the criteria 
available. Our diagnosis may still be in error, unless we possess ac- 
curate information concerning the previous experience of the individual, 
due to the fact that behavior is founded on past experience. 

Page and Page (i) have examined the criteria for admission to a 
mental hospital. They find the following rules have come into 
general use : 

"(i) Does the individual engage in psychomotor, ideational, or 
emotional behavior that is inappropriate to the situation and out of 
keeping with his cultural background? Some examples are: delusions, 
hallucinations, compulsions, mannerisms, psychomotor disturbances, 
speech abnormalities, talking to self, unprovoked elation or sadness, 
etc. These reactions, while not necessarily a source of danger to self 
or others, are regarded by the individual's associates as bizarre, peculiar, 


inexplicable, and annoying; and hence are socially disapproved and 
often feared. 

(2) Does the individual exhibit traits detrimental or dangerous to 
himself, as, for example, does he wander about in a confused disoriented 
state, does he squander his money, mutilate himself or attempt suicide? 

(3) Does the individual engage in activities that are a source of 
potential or actual danger to the welfare of others? For instance, is he 
assaultive or threatening toward innocent bystanders, destructive of 
property, or guilty of sexual and other criminal offenses?" 

A breakdown of the various components of behavior is given by the 
authors in the following quotation: "It was found that 18 per cent 
of the group engaged in behavior directly affecting the safety and 
welfare of others, 74 per cent in behavior detrimental to the self, and 
99 per cent in actions which, though relatively innocuous, were dis- 
turbing to others because of their bizarre nature. Emotional-social 
and thought disturbances were noted in 88 per cent of the cases. Fifty- 
six per cent exhibited speech abnormalities, 45 per cent memory defects, 
and 40 per cent psychomotor disorders. Delusions were the most 
prevalent of the individual symptoms, with an incidence rate of 46 
per cent. Hallucinations were noted in 28 per cent and suicidal tenden- 
cies in 1 6 per cent. Fifteen per cent of the patients were described 
as destructive or assaultive." 


A large part of abnormal psychology is concerned with the topic of 
learning and habit formation. If it may be assumed that the infant 
develops psychologically by means of activity, it is also fair to assume 
that in that growth (both mental and physical) some malformation and 
malfunctioning may occur. It has been clearly demonstrated for 
animals and birds that many of the socalled instinctive or inherited 
activities are not inherited at all, in the popular sense of the word 
"inherited." For example: the cat's "instinctive" tendency to catch 
mice and rats has been shown to be learned. The tendency for chicks 
to pick at small objects, and their ability to stand alone seem to be 
dependent upon movements which have occurred earlier in the shell. 
In children, most of the "instinctive" tendencies are purely mythical. 
Sucking, fear of animals, and many other forms of activity are learned. 
In the process of learning, many good habits as well as many bad habits 
are acquired. The individual is constantly faced with the problem 
of destroying or breaking down the bad habits, and replacing these with 


desirable habits. Much of the difficulty with humans, then, involves 
the inability to destroy these undesirable habits. The important prob- 
lem is not one of recognizing the unwanted habits, but it is one of finding 
a suitable means of combating them. Bad habits are of every psycho- 
logical type. Faulty habits of perceiving (illusions); faulty habits of 
thinking (delusions) ; faulty habits of feeling (apathy, etc.) ; and faulty 
habits of acting (stammering, functional paralysis); are acquired as 
development occurs. This classification is not complete; more will be 
said of these disorders in later chapters. The acquisition of faulty 
habits is not limited to the developmental period; they may be sub- 
stituted for correct habits which have already been established. The 
importance of habit formation in abnormal psychology is so great that 
it is not apt to be overemphasized. 


In the past some writers in the field under discussion have attempted 
to distinguish between this field and psychiatry. In many instances, 
the distinction has not been clear-cut. Perhaps those who have not 
separated the two fields have been deliberate in their action, since the 
distinction becomes progressively more difficult as more information is 
secured by research in both fields. Investigators in the field of 
psychology are constantly demonstrating the interrelation of mental 
activity and physiological and organic conditions. Likewise, research 
in the field of medicine is supplying us, almost daily, with additional 
facts demonstrating the influence of nutrition, bacterial infection, cir- 
culatory failures, and pathological changes in neural tissue and in the 
various vital organs, on mental activity. With this close relationship, 
it is perhaps undesirable to approach any of the biological sciences 
from too widely divergent points of view. The importance of the state- 
ment will be more significant as the reader masters some of the later 
chapters in the text. Although the distinction between psychiatry 
and abnormal psychology is difficult to make, since both psychologists 
and psychiatrists must deal, by necessity, with the same material, the 
behavior of human beings, there are certain practical distinctions that 
are useful. Abnormal psychology was defined, or rather described, as 
the science which formulates the rules and principles applicable to 
unusual forms of behavior. In contrast with this, psychiatry deals 
with the diagnosis, classification and treatment of mental diseases. 
It might be expected on a basis of these definitions that psychiatrists 
would be concerned only with treatment and that abnormal psychologists 


would be concerned only with formulating hypotheses and submitting 
these to tests. In practice, both groups must engage in both types of 
work. In any case, the psychologist must insist on a thorough physical 
examination by a competent physician in order that organic conditions 
may be ascertained. This is necessary not merely to check the organic 
basis of the mental condition but also to reveal the detailed condition 
of the organism. Medical treatment in conjunction with the psycho- 
logical adjustment will often be required. Many people think of 
psychiatric work in terms of hospitalization with "crazy" or insane 
individuals, without realizing that all varieties of nervous patients are 
treated under it. Stigma may become attached to any one who seeks 
advice or treatment from a psychiatrist or a psychiatric hospital. This 
notion, of course, is not justified but nevertheless prevails. Psychiatry 
from the lay point of view deals primarily with cases needing hospital- 
ization. The same attitude does not prevail toward psychologists. 
This is due to the fact that psychologists have not been associated by the 
public with hospitals in which violent or very disturbed cases are kept. 


In discussing the relation of the other sciences to abnormal psychol- 
ogy, we are confronted with a somewhat similar situation. No one 
science is sufficient unto itself. The main differentiation is a matter of 
emphasis. Sociology, clinical psychology, social psychology, neurology, 
and mental hygiene are interrelated with each other, and they are also 
closely related to abnormal psychology and psychiatry. 

In social psychology, there are many concepts that play a very im- 
portant role in the formulation of theories and explanations of group 
life and group activity, which are also of the utmost importance for the 
field of abnormal psychology. If some of these concepts are examined, 
and their usefulness in both fields pointed out, clearness will be more 
readily attained. 

A phenomenon important in both fields is that of suggestion. Sug- 
gestion has been used to remove hysterical symptoms; it has also been 
used to explain the causation of these symptoms. Here, we are dealing 
with both individual and social behavior. Strangely enough, Tarde 
has developed a whole system of social psychology in which he explains 
groupings and group action on a basis of suggestion. The founding of 
one of our large religious denominations (social group) had its origin 
in the demonstrations of hypnosis by Braid and Quimby. 

Another concept common to social psychology and abnormal psy- 


chology is that of the instincts. The dynamic function of instincts 
(urges, impulses) in the psychology of Freud and the analysts is well 
known. McDougall, Trotter, and Veblen have attributed to the same 
concept the formation of our complex social structure and social laws. 
Trotter's book on the Instincts of the Herd in Peace and War, and Mc- 
Dougall's Social Psychology, are excellent examples of the use of in- 
stinctive tendencies for explaining social interaction. Even family 
adjustment and family problems become involved in this situation. 
Freud's Oedipus and Electra complexes are typical examples of ab- 
normal behavior arising from instinctive tendencies, while some social 
psychologists postulate mating on a basis of paternal or maternal 
instincts. It is not the purpose of the text to go into the validity of 
these statements at this point. It may be said, however, that instincts 
as factors in both social and abnormal psychology are fast becoming 

Crime, since Lombroso, has been one of the favorite topics for workers 
in both the social and the abnormal fields, some viewing it from the 
criminal or abnormal side, others as a social situation aggravated to a 
considerable degree by sociological factors. 

Social psychology is a study of groups and is concerned with the indi- 
vidual only to the extent that social groups are composed of individuals 
and in so far as grouping influences individual reactions. Two illus- 
trations by Lindemann 1 (2) show clearly the source of the factors at work 
in formulating group laws and group action. These also indicate some 
of the material which the social psychologist must explain (if possible), 
or at least must arrange in an orderly way. 

In an extremely backward rural community of the Middle West, there exists a par- 
ticularly stubborn resistance to change in agricultural practices and methods, a resistance 
that is not common to the surrounding communities. A recurrent phrase used by the 
residents of this community whenever confronted with a proposal emanating from the 
"outside" gave the clue to this community mind set. The natives met each approach, 
whether of the commercial agent or the representative of the agricultural college, with a 
suspicious response accompanied by the term "Bohemian oats." Investigation revealed 
that this phrase originated more than a half a century before, when an unscrupulous sales- 
man had sold what he pictured as a superior brand of oat seed to the fathers and grand- 
fathers of the present generation. The agent named his seed "Bohemian oats" and 
upon the basis of the claims that he put forth, agreed to buy five bushels of seed from each 
farmer at harvest time for each bushel sold to the farmer. The whole transaction was 
a fraud and the salesman was later apprehended and sent to prison. But "Bohemian 
oats" became a tradition in this community that endured for three generations and so far 

1 Lindemann has presented both the situation and comment. 


conditioned the behavior of its residents as to cause a distinct differentiation between it 
and its neighboring communities. 

Comment: The abnormal feature of this situation lies in the fact that an attitude of 
suspicion toward the outsider which is, of course, normal enough for pioneer communi- 
ties was perpetuated as a tradition and ultimately became a folk myth. Consequently, 
it not only conditioned the conduct of residents, but actually shut them out from evolving 
experiences. Community mind sets of this sort furnish the basis for gradients of com- 
munity development. They begin as rational reactions to disappointing experiences and 
culminate as irrational fixations toward whole areas of possible experience. 

In a one-factory town the president of the corporation and his wife, being public- 
spirited persons, have supplied both the initiative and the resources for practically all 
community projects. They were instrumental in services of the Y. M. C. A., the 
Y. W. C. A., the Red Cross, a dental clinic, and so forth. Whenever anything new hap- 
pens in this community, its origins may be traced directly to this industry and to the 
president or his wife. In recent years, however, this industry has suffered reverses; the 
president and his wife spend diminishing portions of each year in the community and 
increasing portions in travel. Spme of the social and recreational services that they 
initiated have already disappeared and others are sustained with difficulty. It now 
becomes necessary to appeal to the citizens for support, but such support is invariably 
lacking. Indeed, the residents now reveal attitudes of hostility toward their former 
benefactors, and the community as a whole sinks to lower and lower levels of responsi- 
bility and activity. 

Comment: As in most instances of paternalism, this community illustrates how a 
normal community process may become abnormal, when those with superior resources 
assume too much responsibility. Such persons invariably prevent the community from 
developing its own resources and thus, in the end, undermine its capacities. The fact 
that persons thus demoralized should come to feel contempt for their former benefactors 
is thus easily understood as a part of abnormal human relations. Over-solicitude extended 
to communities may have the same consequences as those visited upon the child by his 
over-protective mother. 


Sociology is intimately related to abnormal psychology. Sociological 
factors (living quarters, finances, size of families) play an important 
role in the lives of everyone. It is also obvious that these factors are 
of the utmost importance in determining the behavior and attitude of 
individuals. No psychologist or psychiatrist would be willing to under- 
take the treatment of a maladjusted individual without having informa- 
tion on these points. Crime, which was mentioned earlier, has been 
held to be due almost entirely to environmental factors. Patients in 
mental hospitals as a result of monetary losses due to a depression 
illustrate admirably the influence of sociological and economic condi- 
tions on mental life. Evidence reported by Landis (3) and others 
indicates that although economic conditions may be one of the con- 


tributing factors toward mental illness, no appreciable increase of pa- 
tients in mental hospitals resulted from the last depression. More 
recent evidence presented by Landis and Page (4) shows that the inci- 
dence of mental disorder is related to the bed capacity and facilities 
of hospitals rather than to war and depression. The information pre- 
sented in figures 3 and 4 shows that since 1910 there has been no serious 

FIG. 3. 

peak of admissions for any age group and for any particular type of 
mental disorder with the exceptions of those over 70 years of age and 
cases diagnosed as cerebral arteriosclerotic. The increase in the older 
age group represents better physical care at earlier age levels and 
more liberal admission practices, while the increase in the number of cere- 
bral arteriosclerotics probably can be explained on a basis of shifts in 
psychiatric diagnosis. Whether prohibition has an influence on the 


incidence of alcoholic psychoses is not clear. Nineteen twenty (pre- 
prohibition) was one of the low incidence years. This low rate was 
not maintained with the advent of prohibition. The incidence rate 
started climbing and approached a high level prior to the 1920 period. 


O 45 













O 10 





1925 1930 




FIG. 4. 

There is a tremendous volume of literature dealing with the impact 
of the war on the incidence of mental disorder. The major portion of 
the literature tends to show that there is little evidence to support the 
notion that war in itself results in a greater incidence of mental disorder. 


There is some evidence to the contrary. Some classes of disorder tend 
to decrease in number. The magnitude of the problem and its social 
implications can be readily seen when we point out the fact that of 
every 1000 registrants examined for the draft in this country 43.7 cases 
were rejected because of mental or neurological disability (5). These 
figures do not include the cases rejected because of mental deficiency. 
The incidence is still higher if those cases are included who are subse- 
quently discharged from the army before reaching combat zones. 
Woodward (6) reports that of 80,607 selective service men discharged 
prior to combat action, 26,000 or about 32 per cent were dismissed 
because of mental or nervous disorder. Are these cases caused by the 
war and army service or are these the result of inadequate psychiatric 
selection at the time of induction? The opinion is expressed in this 
report that about 75 per cent of the draftees who suffer mental break- 
down during the training period had mental illness of varying degrees 


Rejections for psychiatric disorders in communities of different sizes 

Semi-rural communities 1 1 . 6% 

Towns 8. % 

Small cities 9-4% 

Medium sized cities 9 . 8% 

Large cities 12.4% 

of severity before being inducted into the army. These results are in 
line with the conclusion drawn earlier in this chapter and are supported 
by the careful study of Hemphill (7) on 354 civilian cases in England. 
He found that of 354 cases admitted to a mental hospital in 1940, only 
29 could be attributed to the war. He states, in addition, that pre- 
existing family life or constitutional taints may have rendered these 
individuals more susceptible to mental disorder. 

Other areas in which sociologists have made contributions to our 
understanding of mental disorder are exemplified by studies of popula- 
tion densities, income levels, occupational prestige, national origins of 
peoples, cultures, and related topics. A brief summary of the influence 
of these factors on the incidence of mental disorder will aid in bringing 
them into perspective. It has been found by Hyde and Kingsley (8) 
that rejection for mental disorder among selectees for the draft in 
Massachusetts varied with the size of the community and population 
density. The rejection rate was highest in semi-rural communities and 
in large cities. This relationship is presented in table I. 


There is in addition, a tendency, according to Blockman and Klebanoff 
(9) for migration of certain types of the mentally disordered from one 
kind of area to another. Schizophrenics migrate towards rural environ- 
ments, while manic-depressives migrate towards urban environments. 
It has been suggested that the rural areas allow the withdrawn schizoid 
to continue his withdrawn isolated existence, while the cities tend to 
provide the excitement demanded by the manic-depressive groups. 

Investigations by Hyde and Kingsley (10) show that whereas only 
7.3 per cent of inductees were rejected from the best socio-economic 
level, 1 6. 6 per cent were rejected from the poorest type of socio-economic 
level. These varying levels contribute also in differing degrees to the 
various classes of mental disability. Income and occupational prestige 
are tied in with socio-economic level and with population density, since 
a study by Clark (n) of some 3000 first admission mental hospital 
cases (schizophrenics) indicates a correlation of .80 between occupa- 
tional prestige and the admission rate for that occupation. Job prestige 
is closely associated with income. Some of the reasons suggested for 
this relationship are: 

a. Personality make-up of these patients handicaps them in job 
competition and promotion 

b. There is greater job security and satisfaction in higher grade jobs 

c. Choice of jobs, and the individual's own estimate of worth is in- 
fluenced by income 

The social psychologist and the sociologist, in their consideration of 
personality development, stress the social forces that impinge upon the 
individual. It might be expected therefore that attention would be 
directed toward the problems of the foreign born. Since their customs, 
language, and self-isolation build up frustrating barriers, the hypothesis 
is logically developed that we might expect a higher incidence of mental 
disorder. Studies have been published on this general thesis by Hyde 
and Chisholm (12), Klopfer (13), Malzberg (14), and Lemert (15). 
First admissions to mental hospitals show that foreign born exceed the 
native born by a high percentage, but when the percentages are corrected 
for age and environment (rural vs. urban) the difference is about 8 per 
cent. If a new culture constitutes a real barrier to adjustment, then 
the children of parents who are foreign born should show an incidence 
rate of mental disorder approximating that of the native population. 
This thesis has been verified on total first admission rate as well as 
first admission rates for specific types of disorder. 

In comparing the influence of culture systems on the incidence of 



mental disorder, studies have been made of primitive peoples, almost 
all nationalities and religious groups. Carother's study (16) will illus- 
trate the general approach. A comparison has been made of the inci- 
dence of mental disorders in Kenya Africans with the incidence of 
mental disorder in American Negroes. _ The comparison is presented in 
table 2. 

Admission proportions in percentages 




Organic psychoses 





1 6 

1 I 

Mental deficiency 

11. 6 



i .0 



28 7 

27 1 




Manic-depressive psychoses 


8 -i 

Involutional melancholia 

1 .4 



2. 1 


Unclassified psychoses 

II. 7 



Percentages of rejectees 














II .7 





24. c 

Italian . . 

4. < 


1 .2 



f Q 

2. C 


I .2 



4. 1 


-7. I 


2. C 

r 2 



Old American 

I . 




Table 3, from Hyde and Chisholm, gives data on individuals from 
various national groups who were rejected by screening examinations 
for army service. 

The data in tables 2 and 3 are not directly comparable, since the data 
in table 2 are derived from those cases admitted to hospitals, and the 


data in table 3 are derived from non-hospitalized cases. The comparison 
points, however, to cultural differences which influence both incidence 
and variety of mental disorder. 


Mental hygiene is a relatively recent development. Its purpose is 
to inform the public of the correct rules for sane mental living. It 
should serve a purpose similar to that of preventive medicine which 
develops and applies diphtheria toxin antitoxin. In other words, it 
has a preventive function. The educational program of mental hygiene 
must fill the place of a course in abnormal psychology for the majority 
of the population. Mental hygienists are advocates of parent training 
so that incipient neurotic conditions will be detected in childhood, 
believing that by proper training methods these incipient cases will be 

An approach to this is illustrated by a study of the problems arising 
in an average high school population (17). Students were asked to 
answer the following questions: 

1. Have you ever had asthma, hay fever, hives, or allergies? 

2. a. Have you ever stuttered? 

b. Do you stutter occasionally? 

3. a. Do you attend mixed social gatherings (of boys and girls)? 
b. Have you ever had a date with a member of the opposite sex? 

4. Have you ever had kidney trouble? If so, has it been within 
the past two years? 

5. Are you bothered by nightmares, intense fears, by walking or 
talking in your sleep? 

6. Does the excitement of examinations affect your eating or sleep- 

7. Are you bothered by "choking" spells, i.e., shortness of breath 
and pounding of the heart when excited? 

8. Do you have to watch your diet because of pain before or after 

9. Have you ever had a falling spell (fit)? 

10. Have you ever had fainting or dizzy spells? 

About 50 per cent of the high school juniors and seniors reported one 
or more of these symptoms. Since such a large part of the population 
has experienced these symptoms, it would seem imperative to find out 
how such symptoms are reflected in behavior and personality develop- 
ment. There is little evidence, however, to show that such manifesta- 


tions prevent the affected individual from meeting the demands of high 
school life. There was found also very little correlation between be- 
havior deviation of other kinds, physical findings on medical check-up, 
and the occurrence of the types of symptoms in the questionnaire. 
The study is important even in the absence of positive findings, since 
it represents an attempt to screen out possible problem cases in the 
young population. Mental hygienists advocate training to cover many 
other fields of adjustment, so that adults may be better able to meet the 
emergencies which arise in their mental life. This work has been at- 
tempted in many of the clinics for child guidance. Since many habits 
are not already formed and since children are more pliable than adults, 
a vast amount of work may be accomplished in teaching desirable habits 
of living in the early years. It must be emphasized that the effort is 
one of instilling correct mental habits in normal individuals in contrast 
with the work done by the psychiatrist, who attempts to alter or change 
habits that are faulty and well fixed. 


There is one other field that is directly related to the topic of abnormal 
psychology and which is the source of some confusion to many. This 
is the field of neurology. Neurology is a study of the structure and 
growth of the nervous system, including the brain, spinal cord and the 
receptors of the special senses. It treats of the various types of cellular 
structure and their physiology. In its narrower meaning the function 
of the brain and neural pathways is outside of its sphere. By function 
is meant what is ordinarily treated in general psychology under the 
topics of perceiving, thinking and associating or learning. It is to be 
expected that the psychologist and the neurologist should have a com- 
petent understanding of both fields. It also happens that both must 
from time to time use the methods and techniques belonging to the 
other. In determining whether certain conditions such as paralysis, 
blindness or anesthesia are the result of a lesion in the neural pathway 
or whether they are the result of a functional disturbance of the asso- 
ciating mechanism, recourse must be had to both the neurologist and 
psychologist. In the case of "glove anesthesia," for example, a con- 
dition in which there is psychological loss of sensation of the hand, 
following approximately the area covered by a glove, the neurologist 
can definitely say that it is not organic, since the loss of sensation does 
not conform to the known ramification of the nerves of the hand. The 
neurologist cannot say, however, what factors are involved in producing 


the condition, nor prescribe the treatment to be administered, since no 
medicament has been discovered for treating such cases. 

The foregoing treatment ot the various sciences should enable the 
student to form ideas of the relations between them. It should also 
enable him to recognize some of the limitations of each science. 


Psychosomatic medicine is a term that has come into popular use in 
relatively recent years, although the basic concepts underlying the term 
are almost as old as the scientific approach to medicine. Nearly all 
of the older scholars in the field of psychiatry recognized the fact that 
emotional disturbances might produce either temporary or permanent 
changes in organic structures or in physiological functions. The ma- 
jority of the somatic changes that arise are in those areas or functions 
under the control of the autonomic nervous system. Disorders such as 
hypertension, stomach ulcers, cardiac and circulatory impairment, skin 
lesions, and dysfunction of the endocrine glands are usually discussed 
in the literature dealing with psychosomatic medicine. The problem 
is one which will be discussed more fully when organic versus functional 
disorders are reviewed. 



We distinguish sensory abnormalities from perceptual ones on the 
grounds with which you are already familiar in the common distinction 
of sensation and perception. Those perceptual disorders which are due 
specifically to abnormalities of a sensory mechanism are usually classified 
as sensory disorders. That is to say, a sensory abnormality is one in 
which the primary cause is to be found in a defect or faulty function 
of the sense mechanism. 

The defect may be any one of several types : 

a. Congenital defects exist from birth. An example of this sort is 
deafness due to the incomplete development of the cochlea of the ear. 
The receptor mechanism necessary to receive auditory stimulation does 
not form when the other parts of the body develop in the fetus. Myopia 
may be congenital. The eyeball is not properly formed in its develop- 
ment. Congenital defects of other senses are found. 

b. Defects may be due to injuries inflicted by mechanical or chemical 
agencies. Blindness due to the thrusting of something into the eyeball, 
or the splashing of acid in the eyes falls in this category. Such injuries 
are said to be traumatic; that is, from a wound. 

c. Disease is a frequent cause of sensory defect. Deafness may be 
caused by scarlet fever; blindness by syphilis. Tubercular disease of 
the spinal cord produces disordered touch sensation. 

d. Degeneration of organs and tissues not strictly due to disease, 
is a cause of sensory defect. Senile degeneration comes under this 
class, as well as deterioration of vision and of hearing common in old 
age. Degeneration of sense organs, or of other parts of sense mecha- 
nisms may occur, however, in middle life, or even in youth. 

e. Defects are caused by toxins. Toxic injury shades into traumatic 
injury on one side, and into disease effects on the other, but it is useful 
to place some conditions in the toxic class. Wood alcohol, for example, 
taken into the system by drinking or inhalation, may produce blindness, 
or if less severe, color blindness. Tobacco has been suspected of in- 
juring the sense of taste and the sense of vision. 



It is obvious that if any sense is abnormal, perception through that 
sense must be abnormal. On the other hand, persons with normal sense 
mechanisms may have abnormal perception. In hysteria, the patient 
may be blind, but the sense of vision be perfectly normal. The hyster- 
ical person may be tactually anesthetic, or analgesic, on certain areas of 
the body, although the sense mechanisms for touch and for pain are not 
defective or injured. Such abnormalities, although they involve 
abnormal sense perception (or lack of sense perception) are not classed 
as sensory abnormalities, but as perceptual. By sensory abnormality 
or sensory disorder we mean strictly abnormality due to defect, injury, 
degeneration, or poisoning, of the sense mechanism. 

The sensory disorder may be localized in one of several places: 

a. In the sense organ or the accessory structures. For an example, 
blindness may be due to injury to the eyeball, which is the sense organ 
of vision. Deafness may be due to injury to the cochlea, which is the 
sense organ of hearing. 

b. In the afferent or sensory nerve. An instance of this is if the 
optic nerve is injured, or degenerates, visual disorder is caused. Injury 
to afferent nerves running from the skin to the spinal cord may cause 
disorder of touch and the temperature senses on the areas of the body 
supplied by the nerve affected. 

c. In the brain stem, or the spinal cord. All sensory nerves enter 
either the spinal cord or the brain stem, and through these structures 
are connected with the brain. Injury or degeneration of the spinal 
cord or the brain stem may cause sensory disorder. 

d. In the sensory centers in the cerebrum. Each sense has its re- 
ceiving "center" in the cortex of the cerebrum. Injury to the center 
for a sense may cause disorder in that sense. 

In many cases, it is not possible to discover the locus of the sensory 
disorder. It has been assumed, for example, that color blindness is 
due to an abnormal condition of the retina; that is, it is localized in the 
sense organ. This, however, may be questionable. The trouble may 
be in the cerebral center of vision or even in the brain stem. 

Sensory disorder has mental effects on the person similar to those of 
bodily malformations. The person is excluded from full advantage of 
certain phases of life. If one of his senses is defective, he does not 
perceive as normal persons do, his sensory contents being limited or 
distorted. He is therefore limited with respect to the materials for 
his more complex mental life. Thinking depends upon sense percep- 
tion, and sense data which you cannot perceive you cannot think about 


The seriously color blind man cannot know the world of colors as other 
persons do. His esthetic appreciations are limited by his defect. The 
deaf person may suffer even more. Not only does he fail to perceive 
the rich content of sounds which normal persons perceive, but he may 
be precluded from receiving information conveyed by the speech of 
other persons. The total effects of these limitations vary for different 
individuals. In some cases, they are serious matters, causing further 
mental disorder. In other cases, the effects of the limitation are less 
important. A sensory disorder may be a primary cause of further 
disorder in a given person. Secondary causes may also be at work 
determining the character and severity of the disorder. 

The results of the individual's knowledge of his sensory abnormality 
may be a serious factor in enhancing disorder. Knowledge of a definite 
sensory disorder, such as partial blindness or partial deafness, may breed 
further causes of disorder. This is also true of bodily defects. 

The person may think that others regard him with scorn, contempt, 
or even merely as inferior. If he is treated with especial consideration 
and kindness, on account of the defect, his condition may be as pointedly 
emphasized as if he were laughed at or struck. 

We might expect an individual with a particular sensory defect to 
develop an abnormal condition with the sensory defect as the primary 
cause, especially if the condition is coupled with secondary causes 
derived from improper evaluation of the defect. Some people become 
seriously depressed and morbidly timid; others develop a truculent 
attitude or become apathetic. 

A few examples from the many that may be cited will illustrate the 
importance of sensory defects in shaping the mental life of the individual. 

An individual who had been studying art for some time began to make 
rather grotesque combinations of colors; it was found upon subsequent 
testing that he was color blind. The emotional response to this situa- 
tion readily developed into a morbid condition. In fact, it meant that 
the individual's life had to be altered and his cherished ambition had to 
be cast aside. 

Another individual was refused an automobile driver's license because 
of a deficiency in hearing. Not only was that individual deprived of 
the personal satisfaction of driving but his social contacts were narrowed 
and competition with members of his own sex for one of the opposite 
sex was made more difficult. 

Loss of sensation in the genital organs was even more disastrous for 
the sex experience and marital adjustment of the person so afflicted. 


It is not hard to conceive of the withdrawal of this person from social 
contacts and the consequent development of a depression. 

Deprivations of the other senses are not so important for the social 
life of the individual and are not likely to bring about as marked con- 
flicts with the desires and feelings of the person. 


In obtaining a complete picture of the abnormal individual it is 
desirable to compare the percentage of sensory defect occurring in 
psychopathic individuals with the percentage of the total population 
which manifest such defects. The approximate percentage of people 
who manifest defects of the two most important senses is given by 
Sydenstricker and Britten (18). They found from examining 100,000 
records of the Life Extension Institute that 57 per cent of native born 
males had some kind of defective vision. Tests were made with the 
Snellen and Jaeger charts. Defective hearing was present in 15.9 per 
cent. A defect was noted if the test with the whispered voice gave less 
than 10 for either ear. The publication of the White House Conference 
on Child Health and Protection gives an estimate of 20 per cent of 
visual defects and 14 per cent of auditory defects among school children. 

Recent data (5) obtained from examination of men in the selective 
service procedure throws additional light on visual and auditory defects 
in the adult population. About 12 per cent were rejected because of 
T /isual defects and 5 per cent for auditory defects. These figures are 
lower than those given above since the standards were less rigid and 
since the age groups involved were more restricted. 

For the psychopathic group, our knowledge of the defects of the 
special senses is slight. Using as a basis for estimation the frequency 
of visual and auditory defects among 100 unselected male cases admitted 
at the Sheppard-Pratt Hospital, the following percentages have been 
obtained. Thirty-eight per cent of the patients showed visual defects 
and 10 per cent of the cases showed auditory defects. More signifi- 
cance could be attached to the findings for the normal population as well 
as to the findings for the psychopathic group, provided an analysis of 
the types of defect was made. In both groups the defects range from 
a slight deficiency to a total loss of both senses. 

A comparison of the percentage of auditory and visual defects for the 
psychopathic and normal population does not throw much light on the 
significance of these disorders in producing psychotic conditions. 
Adler has maintained, nevertheless, that sensory and organic deficiencies 


are paramount in influencing mental activities. In speaking of neurosis, 
Adler suggests that the individual goal of superiority is the determining 
factor. The goal, however, always originates in and is strictly con- 
ditioned by the actual experiences of inferiority. In his earlier works, 
he held that these experiences of inferiority originated in organic in- 
feriority. Farnsworth (19) has attempted to ascertain the merits of 
the Adlerian thesis by comparing certain sensory capacities of groups 
of children and adults who have or do not have musical and artistic 
ability. He examined the auditory acuity and the color weaknesses 
of different groups and found that those who were superior in musical 
and artistic ability were not inferior in auditory acuity and color sen- 
sitivity. These facts do not substantiate Adler's thesis. 

It should be pointed out, however, that sensory deficiency of any 
kind may leave some influence on the further mental life of the 

For the other special senses, including the cutaneous, the olfactory, 
the gustatory, the vestibular, the kinesthetic, the somatic and the vis- 
ceral, no figures are to be had which would enable one to make a de- 
termination of the frequency of defects. This lack of information 
concerning the normal and psychopathic groups prevents the presenta- 
tion of a complete picture. 

Malzberg (20) states that the rate of mortality at corresponding ages 
is from 3 to 6 times as great among patients with mental disease as 
among the general population. This may be expected, since many cases 
with mental disease have other pathological conditions, such as arterio- 
sclerosis, general paralysis and disease of the central nervous system. 
Even those cases which fall into groups that are described as functional 
also show a higher mortality rate than the rate for the general popula- 
tion. Although functional types of mental disease cannot be shown 
to have a specific organic origin, we may, on a basis of the information 
available, suspect some constitutional inferiority as a contributing fac- 
tor. Kaplan (21) has reviewed the literature relative to the role of 
the nervous system in aging. His study on life expectancy of low grade 
mental defectives indicates that incapacities directly associated with 
mental deficiency seem to be a minor cause of death and that "intelli- 
gence" per se is not essential to longevity. 


In the subsequent treatment of the sensory material, some of the 
technical names of the modal senses in table 4 will be employed. 


Technical names of modal senses 





















Tact (ion) 



Pressure sense 




Warmth sense 




Cold sense 




Tickle sense 




Vibration sense 

Palmes thesis 



Pain sense 




Vertigo sense 


Movement sense 




Sexual sense 


Fatigue sense 

Reprinted by permission from Knight Dunlap, Elements of Scientific Psychology. 
C. V. Mosby Co. 


In the first column of this table the common English names are given; 
in the second column, the more technical names derived from the Greek 
or Latin; in the third column, the terms for the absence of sensitivity, 
that is, for the absence of responses to the data of a given sense. The 
fourth column includes adjectives applying to the sensitivity and to the 
sense data. The introduction of certain other terms at this time will 
also facilitate the comprehension of the text. These terms are used 
as prefixes in abnormal psychology and psychiatry, and some of them 
occur in non-technical language. The list of these prefixes includes : 

a-, absence of macro-, large 

ab-, away from micro-, small 

dys-, faulty syn-, together 

hemi-, half para-, disordered; accessory to; 

homo-, similar closely resembling 

hyper-, increase -ids, inflammation (suffix) 

hypo-, decrease 

Although a complete list of the modal senses has been presented, not 
all of them will be treated in detail in this chapter. Since some of the 
proprioceptive and interoceptive sensations can be discussed more 
advantageously along with desires and feelings, they will receive con- 
sideration later. 


The defects of the special senses include anatomical and functional 
conditions. The anatomical or organic deficiencies of the visual sense 
consist of those of the lens system, the receptors for chromatic and 
achromatic light, and lesions of the optic nerve or sensory cortex. 
Functional deficiencies may manifest themselves in any one of numerous 
ways. It is sometimes difficult to decide without comprehensive lab- 
oratory tests which variety is involved. The main distinguishing 
feature of the functional type lies in the fact that no organic or anatom- 
ical defect can be detected. Hurst (22) explains functional disorders 
of the special sense on a basis of a sticking or retraction of the dendrites 
at the synaptic connection. His point of view has been criticized by 
other theorists. His theory as well as the objections to it will be am- 
plified in our later discussions. It must be remembered that for all of 
the special senses both organic and functional disorders have been found. 

The variety and percentage of visual disorders found among the 
registrants for the draft are presented in table 5. It is obvious that 




Blindness, bilateral .07 

Blindness, unilateral .58 

Amblyopia .31 

Blindness, partial .16 

Vision defective or insufficient 1.6 

Astigmatism .58 

Hyperopia .18 

Myopia i .75 

Errors of refraction, other, unspecified 3 .08 

Ptosis, eyelid .09 

Cornea, diseases of .29 

Choroiditis .03 

Phthisis bulbi .01 

Iris, diseases of .04 

Synechia .04 

Night blindness * 

Retina detached .02 

Retinitis .09 

Color blind , .10 

Optic nerve, diseases of .06 

Exophthalmos .13 

Glaucoma .01 

Cataract .21 

Aphakia .02 

Pupillary abnormalities .22 

Strabismus .77 

Nystagmus .15 

Congenital anomalies of eyes, lids .03 

Eye, injury .22 

Eyelids, injury .01 

* Percentage is negligible. 


lens defects or defects of acuity afford the greatest number of cases in 
vision. In many instances the relation of the refractive power to the 
distance separating the retina from the crystalline lens is at fault. The 
abnormalities arising from this source are called hyperopia and myopia. 
They are designated by the lay person as farsightedness and nearsighted- 
ness respectively. Figure 5 shows where the image falls with relation 
to the retina under normal conditions and also under the abnormal 
conditions specified. 

It will be noted in the hyperopic eye that the image normally falls 
behind the retina; this is caused by the unusual shortness of the eyeball 
or the refractive power of the lens. In myopia, the opposite condition 
occurs. The eyeball, being unusually long, causes the image to fall in 
front of the retina. There are two other types of ocular disorders 
ordinarily associated with lens defects. These are astigmatism and 
presbyopia. The former is due to irregular curvature of the lens which 
produces greater refraction in one meridian than in the other; the latter 
is due to hardening of the crystalline lens which prevents accommodation 
for near and far objects. 

The conditions are clinically detectable and may be partially cor- 
rected by the insertion of the proper type of lens before the eye. Hyper- 
opia may be corrected by convex lenses; myopia by concave lenses and 
astigmatism by lenses with cylindrical curvature. Presbyopia may be 
partially corrected by the proper kind of lenses. The type required will 
depend upon the nature of the visual difficulty. 

Among elderly people, near vision may be lost; far vision may be 
intact. Cases of this type may be corrected by lenses for a particular 
distance or small range of distances. For another distance, other 
lenses must be used so that the image will be brought to a clear focus on 
the retina. Kratz (23) attributes myopia to excessive demands on 
accomodation, on convergence, and to weakness of the sclera. Only 
when myopia is associated with astigmatism, neurasthenia, or muscle 
imbalance can improvement through training be expected. Two studies 
indicate improvement may be expected in about 30 per cent of such 

The best controlled study on the effects of training on visual disability 
resulting from myopia is that reported by Woods (24) of the Wilmer 
Clinic. One hundred and three patients with uncomplicated myopia 
were subjected to careful visual tests before eye exercises were intro- 
duced. The training was supervised by an expert in the technique and 


the patients were retested at the clinic upon completion of the training. 
The results were as follows: 

Group i (30 patients) showed a low grade improvement on all visual 
acuity charts 

Group 2 (31 patients) showed a low grade over all improvement 

Group 3 (32 patients) showed no improvement 

Group 4 (10 patients) showed a decrease in acuity 





FIG. 5. Spherical error due to anatomical defect in the shape of the eye-ball. The solid 
rays are the uncorrected incident rays. The dotted rays are the corrected refracted rays. 
The lenses used are those of such power that the refracted rays come to a focus on the 

A less frequent defect which is closely associated with the partial loss 
of accommodation is known as asthenopia. This is the inability to 
maintain muscular contraction because of muscle weakness. When 
the ciliary muscle becomes weakened so that accommodation cannot 
be maintained, blurred vision or a reduction in acuity occurs. This 
type is called accommodative asthenopia. The same phenomena result 


when the external muscles of the eyes become involved (muscular 
asthenopia). Objects appear hazy on the retina since the eye comes to 
rest for only a very brief time. Morgan (25) offers another explanation 
for disorders of accomodation of certain kinds. He postulates changes 
in the mass of the ciliary body due to improper functioning of the vas- 
cular tonus mechanism. 

In some cases, muscular weakness may be restricted to a specific 
muscle causing squint or strabismus. Various forms of squint or stra- 
bismus may occur, since any single muscle or certain combinations of 
muscles may be involved. When certain muscles become involved 
divergent squint arises; when other muscles are involved convergent 
squint takes place. In cross-eyedness or strabismus, when both eyes 
appear to be turned to the right, the internal rectus muscle of the right 
eye and the external rectus muscle of the left eye are affected. Correc- 
tion for asthenopia depends upon the nature of the causal factors. 
Convex lenses will relieve the strain on the ciliary muscle where the 
difficulty involves only one focal distance. In the case of strabismus, 
lenses which will force the eyes to be moved more to the median plane 
for clear vision sometimes strengthen the muscles, when the individual 
is not too old. An operation in which a few fibers of one muscle are 
cut may also relieve the condition. Shure (26) reports that in 65 
adults on whom surgery was performed, 60 gave very favorable results. 
In certain cases the difficulty is not with the muscle. The lack of 
innervation cannot be corrected except by building up the whole 
organism through proper physical hygiene. 

Diplopia or double vision is the result of paralysis or weakening of the 
external muscles or the internal muscles of the eyes (see fig. 6). In 
animals with monocular vision this phenomenon could not occur, since 
it is dependent upon the images of the two eyes falling on non-corre- 
sponding points of the retina. It can be demonstrated in the normal 
individual by holding a finger about 18 inches before the eyes, with 
the tip of the finger just below a small dot on the wall, at several feet 
distance. By converging on the mark on the wall the finger tip may 
be seen double, and by converging on the finger tip the dot will appear 
double. It is theoretically possible that individuals with a very low 
order of intelligence may suffer from this difficulty, since in normal 
depth perception this becomes ignored through a form of development 
or learning. Bielschowsky (27) has discussed the etiology of squint 
and double vision and tends to place emphasis on an additional factor; 
namely that of central fusion. He has shown from a study of 289 




FIG. 6. Illustrating normal binocular vision and the cause of diplopia in convergent 
strabismus. The upper figure shows two eyes converging normally upon the object O, in 
such a manner that its images, 0', 0', are focused on the maculae. Another object A to the 
side of will have its retinal images at A ', A'. Hence, images at A' , A' will be interpreted as 
coming from an obiect at A, while the images on the macula come from 0. The lower figure 
illustrates a convergent strabismus. Note that while one eye is focused normally upon the 
obiect, the other eye is turned in. The line M-N reoresents the optical axis of the turned- 
in eye. Light from now falls to one side of the macula. Images falling upon this portion 
of the retina are projected as coming from one side, and hence one eye perceives in its nor- 
mal position, the other eye perceives projected toward the position A". 

34 tEXtfcObk. Ofr AfcfcORMAL PSYCHOLOGY 

cases that strabismus may result from injury or blindness of one eye. 
He also maintains that muscular weakness or abnormal innervation 
will not be sufficient by themselves to produce anything other than a 
temporary strabismus. 

Thus far, we have been concerned with defects of vision that depend 
in part upon muscular deficiency. There are many other types of defect 
that arise from organic factors in the retina, the optic nerve, and the 
central visual area. In Bridges' (28) classification, the disorders that 
fall in the above categories include amaurosis, amblyopia, hemianopsia, 
concentric narrowing of the field of vision (tunnel vision), scotoma, 
and color blindness. The form of disordered vision that is most fa- 
miliar is blindness (anopsia). The term anopsia is a general one used 
to cover a wide variety of light sensitivity deficiencies due to almost 
any cause. Since the term anopsia embraces many variant conditions, 
more precise terminology will be employed in our discussion. 

Light sensitivity may be completely lost in one or both eyes; for 
the whole visual field or for only part of the visual field. If vision is 
lost in one or both eyes for the whole visual field, it is called monocular 
amaurosis and bilateral amaurosis respectively. While no demon- 
strable lesion of the nervous mechanism is found in such conditions, it 
is generally held that systemic disease or perhaps nerve degeneration 
affecting the retina, the optic nerve or the visual center of the cortex is 

Amblyopia refers to dimness of vision without organic lesion of the 
eye and is employed sometimes synonomously for amaurosis. Mahoney 
and Linhart (29) report 13 cases of hysterical origin. They think 
that the etiological factors are to be found in the inability of individuals 
to cope with their environment. The common features encountered 
in the cases mentioned were a life long history of poor eyesight, uncor- 
rected vision, concentric narrowing of the field of vision, and a charac- 
teristic personality. They were immature emotionally, resigned, and 
poorly endowed mentally. These latter characteristics are at variance 
with those reported later in this chapter by Bender. Corneal anasthesia 
is often concomitant or occurs alone. Miller (30) has examined a large 
group of hysterical patients and reports that out of 69 such cases all 
but 5 had bilateral corneal anasthesia. 

In some cases, blindness for the central portion of the visual field is 
found, while vision in the peripheral field is intact. This condition is 
known as central scotoma. The person thus afflicted cannot see an 


object lying along the optic axis but can see objects lying outside of 
this central area. The reverse of this situation is encountered in con- 
centric narrowing of the field of vision (tunnel vision). The central 
field is visible, but the peripheral limits of the field of vision are reduced. 
Thus objects lying in the periphery are not seen, and numerous traffic 
accidents have been attributed to this cause. Although Charcot and 
Janet considered tunnel vision a stigma of hysteria, Hurst (31) states 
that Babinski and Morax do not corroborate the findings of these 
earlier investigators. They hold that in hysteria the symptoms arise 
from suggestions received during examinations. Baird ^32), in experi- 
ments carried out years ago, attempted to demonstrate that Charcot 
and Janet were correct in contending that concentric narrowing of the 
field of vision was associated with hysteria. He measured the color 
zones of i hysterical and 5 neurasthenic patients with a campimeter. 
The results of the tests on the patients when compared with those of 
3 normal cases supported the contention of Charcot and Janet. It 
should be pointed out that the number of cases was too few to be sig- 
nificant and that the objections of Babinski and Morax were not eli- 
minated. The symptoms may be produced by neuritis of the optic 
nerve or by pressure exerted on the visual area by a brain tumor. 

Bender and Furlow (33) have described the psychological phenomena 
encountered in a soldier six months after injury to the calcarine cortex 
of both occipital lobes. After being completely amaurotic, vision re- 
turned in the peripheral fields with residual large bilateral central 
scotomas. During the recovery period there was good perception of 
motion, defective color vision, little appreciation of form, and ability 
to see best in low illumination. All of these visual functions are char- 
acteristic of peripheral portions of the retina. He possessed normal 
psychological filling in the field of vision, thus perceiving objects as a 
whole. He retained a subjective central point in the blind area which 
made it difficult for him to realize that central vision was lost. There 
was a gradual reorganization of this field of vision when a few functional 
fovea was formed. Subjective visualization of emanating "waves" 
and fluctuation of attention was present. 

The symptoms in this case contrast clearly with those found by Hal- 
stead (34) with other conditions. He has encountered poor peripheral 
vision in patients after removal of a lobe of the brain and in individuals 
subjected to intermittent anoxia caused by high altitudes. Transitory 
peripheral loss is also found in lobotomy. 


Removal of the symptoms depends upon their origin. Operations for 
the removal of brain tumors are successful in some cases; removal of 
the toxic sources will relieve inflammatory conditions. 

In figure 7, the loci of the possible lesions in hemianopsia are shown. 1 
A lesion of the optic tract posterior to the optic chiasma results in the 
loss of vision in the temporal half of one eye and the nasal half of the 
other. Loss of vision of this type is almost always organic in nature, 
although a functional loss may occur among the rare group of individuals 
who have a knowledge of neurology. If there is an actual lesion nothing 
can be done to restore vision. If the disorder is of a functional nature 
associated with hysteria, psychological analysis may relieve the condi- 
tion. Various methods of analysis for functional cases will be set forth 
in a later chapter. Experimental work by Hilgard, Cohen, and Wendt 
(35, 36), has demonstrated that conditioned eyelid reactions and con- 
ditioned verbal reactions can be obtained from hysterical patients by 
the method of reinforcing and inhibiting the eyelid reflexes. When 
stimuli are presented to the blind area, responses are gradually elicited. 
These responses are in contrast with the results obtained from patients 
with organic hemianopsia. 

The point at which the optic nerve enters the fundus of the eye is 
ordinarily referred to as the blind spot. In pathological conditions of 
the retina or of the neural structure of the optic nerve and brain, there 
may be other areas insensitive to light or color. These areas are tech- 
nically called scotomata. They may be detected by the use of a per- 
imeter or campimeter. They are less likely to be of psychological 
origin than many of the other visual disorders. 

It is often found upon clinical examination that there is no actual 
blindness, but reduced or dim vision, for the whole or for part of the 
visual field. In this reduced or dim vision, a distinction is made be- 
tween that due to cataract and that due to amblyopia. 

A cataract is a clouding of the crystalline lens of the eye, occasioned 
by the deposit in the lens of a substance such as a calcium salt or sugar. 
Recent experimental work indicates that such deposits are partially 
dependent upon vitamin deficiency. In many cases, the cataract 
forms late in life. It begins with a slight cloudiness, and progresses, 
sometimes over a period of years, to a density which makes the pupil 
of the eye appear milky or white to another person. This not only 
reduces to a low degree the light transmitted to the retina, but also, 

1 For a detailed study of the neural structure and neural tracts involved, the student 
is referred to Nerve Tracts of the Brain and Cord> by William Keiller. 



by diffusing the light as does milk glass or ground glass, makes vision 
of the forms of objects impossible. The person with a well developed 
cataract can see light, but cannot see objects. His vision is somewhat 
like that of one with a piece of white paper over each eye. 



FIG. 7. Scheme showing semi-decussations of optic nerves. Pulvinar and geniculate 
commissures omitted. Lesions at A would produce monocular blindness, at Chemianop- 
sia, at B t or at D-D, or E-E, total blindness. The left visual field is shown as dotted, the 
right as solid. 

In a few cases the cataract is congenital. The deposits in the lens 
have formed during the intra-uterine life, and the babe is born unable 
to see clearly. These cases are sometimes described as being blind from 
birth; but the condition is not blindness. The visual mechanism is 
usually normal, except for the mechanical screen which cuts down and 
diffuses the light. 


Cataracts usually form in both eyes nearly simultaneously; but in 
some instances, the cataract develops in one eye in advance of the other, 
although before the one has reached its final density the other is on its 
way. Conditions favorable to the development of cataracts are dimin- 
ished metabolism, a decrease in membrane permeability and a loss in 
ascorbic acid. 

The cure for cataract consists in a surgical operation by which the 
clouded lens is removed. The person is then provided with spectacles 
with lenses to compensate for the natural lens. He has vision which is 
normal for objects at a certain distance from the eye; but since the power 
of focussing or accommodating the eye is lost with the removal of the 
crystalline lens, he requires other lenses for other distances. 

Dimness of vision due to conditions in the retina, in the brain, or 
in parts of the visual apparatus between the eye and the brain, is called 
amblyopia. In amblyopic vision, efficiency is lowered because the 
sensitivity to light is reduced but not because of refractive errors. 
The different forms of amblyopia correspond to those of blindness; 
that is general, central, concentric and irregular amblyopia. Certain 
toxic substances such as wood alcohol, arsenic, lead, quinine, and the 
poisons from uremia may give rise to optic neuritis which is responsible 
for the condition. In many cases, the actual cause of the disorder is 
unknown. It is found in some cases of hysteria and hence functional 
origin is postulated as a possible cause. 

A few persons have apparently normal vision in daylight and in 
relatively bright illumination, but are amblyopic in twilight or dim 
light. This peculiarity of vision is termed hemeralopsia. It is some- 
times assumed that the causative factor is the absence of rod cells or 
a deficiency of the visual purple since the rod cells function predom- 
inantly in dim illumination. Barondes (37) stresses the varied causes 
of this disorder and points out that spastic disorders of the retinal 
arterioles may be responsible. Use of vasodilating drugs may then 
correct some types of hemeralopsia by changing the vascular condition. 
Vitamin A and riboflavin in massive doses has been found to be effective 
in overcoming this disorder in a large number of cases. Stewart (38) 
approaches photophobia (undue sensitivity to light) and hemeralopsia 
from a functional viewpoint. These conditions are attributed to a 
feeling of inadequacy in persons of low intelligence; and in persons of 
superior intelligence, to an obsessional meticulosity in work which the 
individual knows could be performed perfectly by others who are less 
able. The visual conditions are therefore defenses. While this explana- 


tion may hold for some cases, it seems untenable for those cases that 
certainly seem to have their origin in organic bases such as fever con- 
ditions and avitaminosis. 

A disorder of vision that is relatively innocuous but a source of an- 
noyance and controversy is color blindness. The term color blindness 
has been used rather indiscriminately by some people. There are 
certain statements usually made about the varieties of color blindness 
that need modification. Instead of having distinct types such as the 
totally color blind, the red-green blind and the blue-yellow blind, there 
is a graded scale ranging from the normal, through the color weak to 
the totally color blind. The totally color blind are achromopsic, that 
is, all of the colors of the spectrum appear to these people as different 
shades or intensities of gray. On a basis of the Young-Helmholtz theory 
of color vision it is supposed that light of any wave length excites all 
three color processes of the color blind in a balanced ratio. Some 
theorists hold that the cone cells are entirely lacking while others 
maintain that the cone cells and rod cells are in a permanent state of 

The partially color blind are referred to as parachromopsic. In this 
category are included the red-green blind and the blue-yellow blind. 
The red-green blind may be further subdivided into deuteranopes and 
protanopes. The scientific terminology is relatively unimportant, but 
the essential differences between the two types should be understood. 
Both the protanope and deuteranope tend to see low saturations of red 
and green as gray or yellowish. Furthermore, the spectrum appears 
to have only two colors, namely blue and yellow. These colors lie on 
either side of the red-green band which appears similar to daylight. 
The main difference between these two classes occurs in the extremely 
long wave length of the spectrum. To the individual with normal eyes, 
light having a wave length of 760 juju (red) is visible; to deuteranopes 
the total length of the visible spectrum at the red end is visible but is 
seen as yellow; to protanopes, the extreme end is not visible even as 
yellow. The exact amount of shortening of the spectrum varies for 
individual cases. In the case of blue-yellow blindness, if there are any 
true cases of this variety, the supposition is that confusion between 
blues and yellows occur. The only portions of the spectrum visible 
to this group would be the reds and greens. Figures 8 and 9 show dis- 
crimination sensibility for hues and distribution of luminosity for 
different kinds of color blindness. The explanation of vision in the 
various types of color blindness will depend somewhat upon the theory 

4 o 




C 'S -Sggcg^ 

Q tso C ^ w, 

^~ f^l'l^s 

^ *, u 
>A' ^& fc 

^4,*, rt V/ _, f-s^ r^ | 

Ofrv ^ o ^2 a 

S S'?5 -3 
nc,w _.3 C D_5 





. / 






rmio"O' o O5f^'^'t' 

ae, wave-lengths of colored light; ordinates, difference 
Curve A: Protanope. Curve B: Deuteranope. C 
imple, the sensibility of the normal trichromat in the 
it should report a JND between 580 and 587, or betw 
;n and blue-green, from about 520 to 495. The co 
and 450, with color perception only for deeo green anc 



























_ - 

. * ' 















t 0.00'00 


iscrimination sensibility for hues. Absciss 
cing discriminated (JND) in units of 10. 
(Data from Steindler's curves.) For ex: 
>=7; this means that the normal trichrorm 
i sensibility of the protanope for pure gre< 
is limited to the region between about 515 

























QJQ boo 


> 059 Sfc^ 

B . 

t ^^* 



vj ~ o c o> r- m - < 






< COO 



B &' 

09* SC^CL, 


4 I 

015 ^. 

1*5 * 

z 8> 


jri'rt O 

t g . 


c .. 

< ^ 



of color vision adopted. In terms of the Young-Helmholtz theory, the 
red and yellow green processes are both stimulated equally when ether 
vibrations of the correct wave length for either red or yellow green 
impinge on the retina, thus producing gray. Blue-yellow blindness 
has been explained in a similar manner. 

The cause of color blindness is a controversial question. Inheritance 
has long been considered as the primary cause. This thesis is based on 
genetic studies in which the ratio of the incidence in the two sexes has 
played a prominent part. It has been reported from various studies 
that there are about 4 times as many color blind males as there are 
color blind females. These figures would seem to favor a sex-linked 
recessive gene, since these are the proportions that would normally be 
expected. However, we must consider that color blindness is arbitrarily 
defined in terms of a particular test. Some individuals fail on plate 
tests (Ishihara, Stilling, A.O.I. Tests) and pass yarn tests. Others 
have normal ability to discriminate hue using a spectrometer as Hamil- 
ton, Briggs and Butler (39) have shown. They found that 50 per cent 
of those who are deficient on the Ishihara had normal wave length 
discrimination on a spectrometer. Scheidt (40) has found that many 
cases with optic neuritis and retinitis fail on both yarn and plate tests. 
Johnson's work (41) on rats indicates that color vision deficiencies may 
be expected in avitaminosis A. Histological studies revealed that in 
the retinas of rats suffering from a deficiency of vitamin A, there was a 
degeneration of visual cells, the internuclear layer, the pigmented epi- 
thelium, and the internuclear layer. If the degeneration had not pro- 
gressed too far, 3 or 4 weeks of therapy repaired the damage. Some 
diabetics show a color deficiency which tends to improve with insulin 
therapy. Burt (42) has called attention to the relation between eye- 
color and defective color vision. His study indicates some relationship 
and he proposes 3 possible explanations: (a) a genetic linkage, (b) pig- 
ment metabolism, and (c) light absorption of certain spectral bands by 
the eye pigment. In addition, retinal pathology and systemic poisoning 
have been postulated as causes. If all of these factors enter into the 
production of different kinds of color blindness and if an individual is 
color blind on one test and not on another, it is difficult to accept 
the genetic theory, except possible in limited types of cases which have 
as yet not been specified. 

In recent years the controversy has been raging as to whether color 
blindness can be alleviated. The controversy was initiated by the 
work of Dunlap and Loken (43) in which they reported that some cases 


of deficiency responded to vitamin A therapy alone or to a combination 
of vitamin A therapy and cobra venom. There have been numerous 
investigations, some tending to confirm, others to negate the results of 
Dunlap. LeGalley and Harrison (44) are among the proponents, while 
Elder (45), Richardson and Kinard (46), Hamilton, Briggs and Butler 
(39), and others, are antagonistic. The preponderance of the data 
tends to demonstrate that color discrimination either on color blind 
tests or on a spectrometer is not improved. Melville (47), and Dvorine 
(48) assign any improvement to training with colors or to better bright- 
ness discrimination. 

The analytic approach to functional color blindness is exemplified 
by the case presented by Fodor, Fodor (49) reports a case of total 
hysterical color blindness in a 29 year old patient in which recovery was 
partially made under analysis: The analyst was able to determine that he 
had once possessed normal color vision but had lost it under difficult 
environmental circumstances. He had been severely punished by his 
teacher at school for attempting to contact the sexual organs of a female 
school companion. The patient was locked in a dark closet and for all 
he could figure out he was blinded in punishment for this misdeed. 
Some time after the kindergarten incident, red vision was blotted out, 
since this was the color of the female genitals. Subsequently vision for 
green was lost, probably due to homosexual relations with an older man 
by that name. How vision for the other colors came to be lost is not 
clear. We see in this case how the dynamics underlying the condition 
were determined by the analyst. 

It is probably not safe to assume that color blindness has no higher 
frequency among psychotic patients than among the population at large 
in view of Hrdlicka's (50) investigation and that of Kaplan and Lynch 
(51). The latter tested 403 cooperative mental patients with the Ishihara 
and Stilling charts. The results are presented below: 


Males Females Males Females 

Total color blindness 2.7% .7% 7.7% .0% 

Red-green blindness 17.9% i -4% 7-7% -% 

Red-green color weak 12.1% 2.4% .0% 10.5% 

Without color defect 67.2% 95.2% 84.6% 89.5% 

While the ratios of the two sexes vary from those usually reported for 
the normal population, no satisfactory explanation is available. The 
differences in the two classifications are likewise not readily explained. 
Neurotic disorders have been suspected of contributing an undue number 


of color blind cases. Dunlap (52) has found that many of his color 
blind cases have neurotic symptoms. Malholm (53) tested with the 
Ishihara Test 165 asthmatic males and 192 males afflicted with hay 
fever. The incidence of color blindness in the total group was 8.4 
per cent. The evidence tends toward the fact that mental disorder is 
accompanied by a somewhat higher incidence of color deficiency than 
is encountered in the normal population. 

The importance of the various vitamins for normal visual activity is 

such that a brief summary at this point would help the student to obtain 

a better over-all picture. Hahn (54) has worked out these relationships. 

Vitamin A: is found in the cornea. It aids in maintenance of intact 

epithelium; it is necessary for normal respiration of the cornea. 
Vitamin A: is found in the retina. It is essential for regeneration of 

visual purple. 

Vitamin Bi (thiamin): is found in the nerve tissue. It is important 
in metabolism of nerve cells, hence in reception and conduction of 
visual stimuli. 
Vitamin B 2 (riboflavin): is found in the cornea. It is necessary for 

respiratory mechanism of cornea. 
Vitamin 62 (riboflavin): is found in retina. It serves a useful purpose 

in light perception. 
Vitamin C: is found in intraocular fluids. It is required for their 

normal secretion. 
Vitamin C: is found in crystalline lens. It aids in metabolism and 

respiration of the lens. 

Vitamin E: is concerned with reparation processes. 
Vitamins K and P: are involved primarily with the blood and blood 


An inadequacy of any one of the vitamins may result in visual dys- 
function. We have pointed out these disorders but a recapitulation is 

Insufficient vitamin A slows down the rate of regeneration of rhodop- 
sin, hence poor light adaptation and night blindness. It may be related 
to poor visual acuity and color vision, especially when tests for the latter 
depend in part on brightness discrimination. Deprivation of fat soluble 
A produces a keratinizing epithelium in place of normal epithelium in 
cornea. This results in vascularization of the substance of the cornea. 
Vitamin B (thiamin, nicotinic acid, riboflavin) aids in utilization of 
carbohydrates. Thiamin deficiency may be accompanied by ophthal- 
moplegia of Wernicke's syndrome and a circulatory syndrome. Insuffi- 



cient riboflavin produces poor visual acuity, dimness of vision, photo- 
phobia and vascularization of the cornea. Vascularization is brought 
about by reduced oxygen level and the attempt of the organism to 
prevent anoxemia. 

Lowered vitamin C is found in cataract and aphakia. 

Deficiencies of the other vitamins are not as clearly worked out in 
relation to specific visual dysfunctions. 

Sardana (55) found 3 well-defined syndromes in his study of 500 cases 
of avitaminosis. The syndromes are given in table 6. 

Even if the condition cannot be corrected, a better adjustment may 
be had by the individual toward his environment if colors are adopted 
for various purposes which will enable the color blind individual to 
make color discriminations on a basis of brightness. This procedure 
will not interfere with those individuals who possess normal vision. 


Vitamin insufficiency syndrome 




Night blindness 
Itching eyes 
Sensitivity of cornea 
Tunnel vision 
Reduced acuity for distance 

Dim vision 
Burning sensations 
Dull pain back of eyeballs 
Poor accommodation 

Hazy vision in sun 
Poor acuity for distance 
Nyctalopia preceded by 

The public is partly cognizant of this fact, and the change in actual 
colors and designs of traffic signals has been a decided aid to the color 

Two visual defects which are in opposite relation to each other are 
macropsia and micropsia. These are subjective estimates of objects 
as too large or too small. These conditions may be the result of organic 
or psychological factors. Micropsia is observed more frequently than 
macropsia, especially when the defect is physiological. Various theories 
have been offered in explanation of these disorders. One is that in 
inflammation of the retina (retinitis) the receptors become displaced or 
rather become separated, so that the receptors which are normally 
stimulated by an object one centimeter square now require an object 
one and one-fifth centimeters square to cover them. Under these 
circumstances the original object appears reduced by approximately 
one-fifth. In macropsia, the opposite might be assumed to occur. 


There is a crowding of the receptors, and an object which would nor- 
mally be interpreted as one centimeter square is now interpreted to be 
one and one-fifth centimeters, since many more retinal units are stimu- 
lated by an object one centimeter square. Some investigators have 
attributed the phenomena of macropsia and micropsia to the psycholog- 
ical effort involved in muscular changes of the crystalline lens. In 
presbyopia and following the injection of atropine, additional effort must 
be made for accommodation. This greater muscular effort in the 
general scheme of space perception affords the idea of nearness. In- 
terpretation of nearness usually means smaller sized objects, hence 

Another point that needs comment is the relation between the rela- 
tive size of the objects on the retina of each eye. Ames, Glidden and 
Ogle (56) have shown that individuals frequently have retinal images 
of the two eyes which differ in size and shape. These have to be fused 
centrally. If we assume that an individual may be dominantly right 
eyed or left eyed; that is if dependence for size and shape is based pri- 
marily on the image of either the right or left eye, then any sudden shift 
of this dominance may give rise to macropsia, or micropsia. Which 
form would occur would depend upon the dominance in the original 
perceptual pattern. 

Southard (57) cites a case following gunshot wounds of the occiput 
in which the individual had Lilliputian hallucinations. Although 
these Lilliputian hallucinations dated from the trauma (wound), other 
mystical delusions concerning Allah and Mohammed dated from early 
childhood. Southard is inclined to explain the Lilliputian hallucina- 
tions by suggestion. The patient, either in examination or from some 
other source, heard of Lilliputians and incorporated them into his 

Inman (58) describes two cases that came under his care. One was a 
boy eight years old; the other, a boy ten years old. The details of the 
anomalies are inadequate for explaining the cases in terms of the theories 
outlined. One of the boys complained of apples growing smaller and 
smaller, while the other said that the dishes, the page of a book and 
even his mother became smaller as he looked at them. Macropsia and 
micropsia are spoken of as signs of hysteria. Moreover, Inman explains 
them on a psychoanalytical basis, tying up the disorders with oral 
fixations of nursing. It is fairly clear that Southard's case, as well as 
Inman's two cases, are not due primarily to sensory disturbances and that 
these types of disorder should possibly be placed in another classification. 


Bender et al. (59) refer to the condition in which the images formed 
by the two eyes are unequal in size, shape, or both, as aniseikonia. 
The test employed for this disorder is described by them as follows: 
"Aniseikonia is measured by presenting to the two eyes paired images 
having a common, central object with horizontal and vertical lines which 
stimulate fusion. Near the ends of these lines (4 from the center) 
are a pair of numbered indicator lines, so polarized that one of each 
pair is seen by each eye. If aniseikonia is not present, the pairs of 
lines appear equidistant from the center and also appear in alignment. 
If aniseikonia is present, the lines seen by one eye appear closer to the 
center than those seen by the other; this condition may occur hori- 
zontally, vertically or in both meridians. Measurement of degree is 
effected by determining the extent to which magnification of one ocular 
image is required to bring the two images into alignment. The per 
cent of difference in size is measured by a calibrated scale on the system 
of lenses, which produces the magnification. The aniseikonia is meas- 
ured at distances of fifteen feet for distant vision and at sixteen inches 
for near vision." 

Burian, Walsh and Bannon (60) estimate from their experience in 
New Hampshire that about 35 per cent of the total population would 
benefit from aniseikonic corrections. The experience of Cushman (61) 
in treating patients gives a somewhat less optimistic picture. Of 24 
patients treated, 14 had complete comfort with aniseikonic lenses; 3 
showed improvement; and 7 showed no improvement or had reading 

While the importance of a visual defect in contributing to a mental 
disorder has been demonstrated in specific instances, very little sys- 
tematic information has been collected, except by Bender (59) and his 
co-workers, that shows how visual defects contribute to the total per- 
sonality pattern in individuals who are not designated as abnormal. 
In a very careful study of 124 college students, they have measured 
visual factors such as hypermetropia (hyperopia), myopia, astigmatism, 
heterophorias and aniseikonia. In addition, they have collected 
data on such psychological factors as intelligence, reading rate, behavior 
description reports, personality, vocational interest and school grades. 
Their conclusions indicate that it is important to correct visual defects 
that interfere with visual efficiency but that it is extremely difficult 
to show the actual influence of such defects on the motivational pattern 
of the individual. There seems to be a two-way adjustment. The 
motivational pattern of the individual influences his adjustment to 


his visual defects and vice versa. The visual condition is so imbedded 
within the personality structure, that its psychological significance is 
not clear. 


The disorders of audition are not only less frequent in number but 
also fewer in variety than disorders of vision. The range of defects is 
more limited because of lack of detailed information concerning the 
actual functioning of the auditory mechanism. 

The percentage of each type of defect for which rejection was made 
under selective service regulations is given in table 7. The location 





e OI 

Deafness bilateral 

J * w 


Deafness, unilateral 



Hearing, defective ... 





Mastoidectomy, result of 


Otitis externa 


Otitis media 


Otitis interna . . 


Tympanic membrane, perforated 


Tympanic membrane, absence of 


Tympanic membrane, other 


Ear deformity of 


Impacted cerumen or foreign body in ear 

I .01 

Ear other conditions of. ... . . . . . 


of these defects anatomically can be ascertained by referring to figure 10 
which shows the general relation of the various parts of the ear. 

Studies on the function of the middle ear have embraced a wide 
number of approaches. The eardrum itself is subject to a variety of 
changes that result in either unilateral or bilateral anacusia. Bordley 
and Hardy (62) have shown that even small incisions of the drum result 
in impairment which is somewhat greater for low tones than for high 
tones. Blocking of the drum, such as occurs when the external meatus 
is filled with wax or when the eardrum is covered artificially with 
vaseline, results predominantly in a decrease in the ability to hear low 
tones. A large rupture of the tympanum, disengagement or fixation 



of the ossicles, or a total lesion of the cochlear branch of the eighth 
cranial nerve produces unilateral deafness. A lesion of this type usually 
involves the vestibular response. Whether both ears will be involved 
by a lesion of the neural pathway depends upon the locus of the lesion. 
There is a crossing of certain fibers from each ear to the opposite superior 
temporal convolution which is presented in figure n. 

Bunch (63) cites a case of a patient whose entire right cerebral 
hemisphere had been removed; nevertheless, tests with the i A audiom- 
eter showed that the auditory acuity of the two ears was approxi- 


FIG. 10. Schematic section through right ear. Au. t auricle; A/., external auditory mea- 
tus; 7".. tympanic membrane; H., malleus; A., incus; ST., stapes; 0., fenestra ovalis; R., 
fenestra rotunda; Sv., scala vestibuli; St., scala tympani; Eu., Eustachian tube; C., cochlea; 
Aud. y auditory branch VIII th nerve; Vest., vestibular branch VHIth nerve; Am., am- 
pulla; Sa., sacculus; U. t utriculus; Se., semi-circular canal; Mu., muscles of ossicles. 

mately normal and equal. He further states that none of the tones 
produced was inaudible in either ear. Investigations on dogs and cats 
by Brogden, Girden, Mettler and Culler (64) who removed one cortex 
gave results similar to those of Bunch on humans. Very little or no 
loss of auditory acuity followed such extirpations. These findings 
indicate that both ears were functionally normal and that the removal 
of the fibers on one side did not prevent those which go to the opposite 
side of the cerebral hemisphere from taking over or performing the 
tasks which may under usual circumstances fall elsewhere. 




FIG. 1 1 . Auditory sensory path. Schematic diagram showing principle sensory connec- 
tions and commissures. Fibers from the left cochlea, shown as banded lines, enter the 
pontine region (indicated by circle) via the auditory branch of the VIII th nerve. (For 
external connections see fig. 8.) Here they branch into the tuberculum acousticum 
('Tub.') and the accessory nucleus (Ace.}. From the tuberculum certain fibers go directly 
to the lateral lemniscus (Lat. /em.) of the same side, and others to the superior olivary nu- 
clei (Sup. oli.} of either side, from where they enter the corresponding lateral lemnisci. 
. Fibers from the accessory nucleus go to both the olivary nucleus and the trapezoid nucleus 
('Trap.) of the same side; from the olivary nucleus to the lateral lemnisci of the same and 
the opposite side, and from the trapezoid nucleus to the lateral lemniscus of the same side, 
or to the lateral lemniscus of the opposite side via the trapezoid nucleus of the opposite side. 
The fibers connecting the olivary and trapezoid nuclei of the two sides form the traoezoid 
body (T.B.). The ending of the left lateral lemniscus is partly in the opposite medial 
geniculate body (Med. gen.} and partly in the inferior colhculi (Inf. coll.}. The inferior 
colliculi are connected by cpmmissural fibers (Com.}. New fibers arise here and enter the 
cerebral lobes through the internal capsule (Int. cap.}. These mixed fibers finally termi- 
nate in the left superior temporal gyrus and the left transverse temporal gyri. Two inter- 
esting tracts leave the region of the olivary bodies and colliculi; one pair downward to spinal 
motor reflexes (S. R.} and one which branches into the two optic tracts (0. *T.}. Lesions or 
injuries at A would result in the deafness of one ear. At B they would have little effect, 
since fibers from both ears would enter both lobes. At Cone of the cerebral lobes would not 
function. (In order to better illustrate these connections, the anatomical proportions 
have been greatly distorted. The student is referred to Gray's Anatomy, figs. 736, 737, 
774, and 778, for the correct anatomical proportions.) 


The influence of fatigue, muscle tonus, and stapes fixation in oto- 
sclerosis, have been pointed out as causes of hypesthesia; in the latter 
instance there is actual lessening of function of the chain of ossicles. 
Movement is reduced because of hardening of the bony tissue at the 
point of attachment of the ossicle mentioned. The interruption of 
the chain of ossicles produces a loss of from about 40-60 decibels accord- 
ing to Wever and Bray (65). Experiments dealing with tension or its 
absence on the tensor tympani muscle and the stapedius muscle, are 
reviewed by Wever (66). The results seem to indicate that increased 
tension causes a decrease in the magnitude of the action potentials 
picked up from the cochlea. These changes in auditory acuity are 
also in line with the known facts about the influence of pressure changes 
on auditory acuity. Most people experience a loss of acuity when the 
eustachian tubes are congested and the middle ear pressure is out of 
balance with the external pressure exerted on the eardrum. Thompson, 
Howe, and Hughson (67) have verified this experimentally by artificially 
producing such pressure changes. The work of Seitz and Smith (68) 
shows an increase of 24 per cent in errors of comprehension in going 
from sea level to high altitude conditions. Middle ear hearing deficiency 
in some patients can be separated from inner ear deficiency by use of 
the bone conduction technique, although this method is not infallible. 
If the sound waves can be made to pass through the skull bones, they 
presumably stimulate either the auditory nerve or the central area 
directly. The mechanical difficulties of the middle ear are circumvented. 

Losses of hearing ascribed to the inner ear range from losses in acuity 
to losses for specific pitches. Crowe and Hughson (69) have shown 
that auditory sensitivity may be improved by blocking up the fenestra 
rotunda by grafting periosteum over it. Work by Culler, Finch, and 
Girden (70) indicates that Crowe and Hughson were in error since 
they found an actual loss. Recent work by Davis et al. (71) tends to 
confirm the contentions of the latter investigators. 

In connection with problems associated with the inner ear, intra- 
labyrinthine pressure has been scrutinized. Culler and co-workers (72) 
have noted that an impairment in hearing results when a saline solution 
is injected and the pressure is increased. Fowler and Forbes (73) 
and Wever and Bray (74) have noted a general decrease in auditory 
responses following the application of various chemical substances to 
the round window. High tones were affected more than low tones. 

As we pass on to an examination of the functions of the cochlea, we 
find that some disorders of audition result from pathology existing in 


this portion of the ear. Most of the work has dealt with destruction of 
portions of the cochlea. Very little can be said at present other than 
the fact that lesions in a given area do affect responses to some fre- 
quencies more than to others, but there is produced a general lessening 
of response to all frequencies. 

Many of the cases of occupational deafness are attributed to patho- 
logical changes in the cochlea due to prolonged stimulation. This is 
borne out by surveys in industries in which a disproportionate number 
of people with deficient hearing are found. Reports have been made 
on the high incidence of nervous disorders developing among women 
war workers who have been subjected to loud noises. Most of the 
effects of noise tend to disappear after a few hours, but in those cases 
that are susceptible, Rosenblith (75) found that noise levels of 75 to 80 
decibels, if sufficiently prolonged, bring about premature aging of the 
ear. Jankoff (76) indicates that extreme temperature changes may 
result in a loss in hearing. Railway engineers showed a marked loss 
in hearing in the right ear which was exposed more than the left ear, 
whereas brakemen tended to show a similar loss for both ears. 

We have as a result of the war, many cases of hearing deficiency in 
aircraft pilots, in aerial gunners, bombadiers, and in ground personnel 
exposed to artillery fire and even to small arms fire. While some cases 
have actual demonstrable pathology of the hearing mechanism, many 
others do not. Malone (77), Ullman (78), and Cope and Johnson (79) 
give representative data on these disorders. Among 100 officer combat 
fliers 66 per cent had a fatigue notch at 2896 cycles per second; 16 per 
cent at 4096 cycles per second; and 18 per cent had mixed forms of 
frequency loss. Ninety-seven of the group showed a loss of some kind. 
Three per cent showed a loss of 100 decibels at one or more frequencies; 
27 per cent showed a loss of 100 decibels at one or more frequencies; 
12 per cent showed a loss of 30 decibels; and 55 per cent showed a loss 
of from 10 to '25 decibels at one or more frequencies. The amount of 
loss is related to flying time up to 2000 hours. Men who exceeded this 
time without loss may not show impairment with increased time. 

It should be pointed out that there is a difference in the apparent 
permanence of the hearing loss engendered by noise from aircraft motors 
and hearing loss arising from altitude changes. Kos (80) finds that the 
latter type of disorder will yield fairly readily to rest and other forms of 
therapy for correction of disorder in the pressure regulating mechanism 
of the ear. 

Loss from exposure to gunfire presents a similar picture. The fre- 
quency range most affected is from 2048 to 4096 cycles per second. 



Tinnitus aurium (acoasma or akoasma) is a subjective ringing or 
roaring sound in the ears. This may be produced temporarily by drugs 
such as quinine, by closing of the eustachian tubes, or by inflammation 
of the middle ear. In some cases, the sounds are continuous and exist 
when no special auditory defect can be detected although tinnitus is 
more frequently found in conjunction with other auditory defects. 
Fowler (81) has found that 85 per cent of patients with aural disease 
have tinnitus as a concomitant. Circulatory disturbances of the inner 
ear, pressure on the ear drum due to improper equalization of atmospheric 
pressure, and continued stimulation of particular neural fibers have been 
suggested as possible causal factors. Goodfriend (82) states that among 
the causes of progressive deafness, tinnitus and vertigo, will be found 
abnormal dental bite. This condition produces chronic irritation of 
typanic membrane, circulation interference and degeneration of tissue. 






Goup I. Vasospastic tinnitus. Treated with nicotinic acid 

15% 48% 

Group II. Vasodilated tinnitus. Treated by histamine desensitization 

3 1 




Atkinson's report (83) on the treatment of tinnitus furnished informa- 
tion on the probable outcome of therapy on selected patients. He 
divided his patients into 2 groups: those whose tinnitus arises from a 
vasospastic condition; and those whose tinnitus probably arises from a 
vasodilated condition. The results of treatment are found in table 8. 

Birth injury, meningitis, and infantile paralysis will produce a variety 
of hearing difficulties. The magnitude of these disorders in contributing 
to hearing loss can be ascertained from Rutherford's survey (84) of 
cerebral palsy children. Forty-one per cent had a hearing loss. It 
was found that the loss was somewhat greater in the pyramidal or 
spastic cases than in the extrapyramidal or athetotic cases. 

The therapeutic technique for hearing deficiency depends upon the 
hearing loss. Unilateral and bilateral anacusia cannot be cured when 
the difficulty arises from a gross lesion of the cochlea. Hypesthesia may 
be aided with suitable amplifiers. A few remarks concerning the 
difficulty of finding a suitable amplifier will point up some of the other 


problems of audition. Watson and Knudsen (85) have presented a 
report on their study on "Selective Amplification in Hearing Aids" 
which students of this field will find very worthwhile. It must be 
remembered that each individual shows a characteristic hearing loss. 
Some people have a loss throughout the entire tonal series, that is a 
decrease in sensitivity to all pitches. Others may experience difficulty 
toward the upper limit of pitch or the lower limit of pitch. Still others 
may have tonal islands and tonal gaps. Most amplifiers are built to 
amplify the speech range; consequently those pitches for which hearing 
is normal will be amplified as well as those for which a deficiency exists. 
The result of this is a distortion to which the individual must adapt. 
Loud sounds are amplified as well as weak sounds. Since the intensity of 
sound varies inversely with the square of the distance, a loud sound 
close by will almost cause pain, whereas a sound of weak intensity 
coming from a distance will just be audible. There are certain other 
sounds arising from the instrument itself which offer confusion in dis- 
tinguishing the sounds of the environment. An audiogram obtained 
by the use of an audiometer will materially aid in determining the 
type of amplifier that is most suitable for the individual. Instruments 
are now built that will fill a specific need, but these are fairly expensive. 

Shambaugh (86) has developed an operation for otosclerosis that he 
reports as being successful in about 88 per cent of the cases on which it 
has been tried. The operation consists in removing the ankylosed bones 
of the middle ear. In a follow-up study on 201 patients (87) one year 
after operation, he found that the hearing was worse in 1.5 per cent of 
patients; unchanged in 2.5 per cent; improved, then lost in 5.5 per cent; 
20 per cent of the patients gained 10 to 20 decibels; 37 per cent gained 
20 to 30 decibels; and 33.5 per cent gained over 30 decibels. While 
these figures are somewhat higher than those from other sources, the 
differences may be accounted for in the selection of patients and in the 
skill of the surgeons. 

Osborn (88) and Fisher (89) have demonstrated that preventive 
therapy with children will decrease progressive deafness. While we 
are not presenting the nature of the disorders underlying the hearing loss, 
the figures of the authors mentioned show that radiation of lymphoid 
tissue which interferes with the functioning of the eustachian tubes, will 
prevent deafness in many cases. Similarly, tests one year apart on 
children with various types of hearing difficulties have confirmed the 
efficacy of therapy. The hearing of 85 per cent of the treated group 
improved, whereas only 23 per cent of the non-treated group showed 


Lawrence (90) has experimented with vitamin A, and others have 
tried prostigmine as therapeutic agents. On the whole the results of 
these agents have not been too encouraging. The latter has been 
found to be effective clinically in selected cases. 

Functional loss of hearing for one or both ears may occur. Likewise 
the loss of hearing for particular words or sounds may be of psycho- 
logical origin. The removal of these deficiencies depends upon the 
discovery of the psychogenic factors involved. A functional type of 
tinnitus is "telephone tinnitus." The nature of the actual sensation 
is very similar to the ringing or buzzing sound made in the telephone 
receiver. This is somewhat of an occupational neurosis, occurring 
from the continual use of the telephone. The etiological factors of 
this neurosis can not be attributed to degeneration of the neural fibers 
through continuous use. 

A case history of a patient with psychogenic deafness is summarized 
from Truex (91). A sergeant, 25 years of age, was admitted to the 
hospital. His military record was excellent. His history was not 
unusual. He had several earaches in childhood but nothing else of 
significance until he was in the Philippines. He was exposed there to 
mortar and artillery fire which caused tinnitus and mild bilateral im- 
paired hearing. Later a mortar shell blast nearby caused a back 
wound, bleeding from both ears, and deafness. Acuity improved some 
on the following day, but then there was no change. The ears revealed 
no abnormality. He was tense, restless and moody. Loss for pure tones 
in speech range averaged 59 and 52 decibels for the two ears. Loss of 
speech however was recorded at 30 decibels. This discrepancy among 
other things suggested functional loss. For example, a day later the 
losses recorded were 87 and 85 decibels for pure tones, and 35 decibels 
for speech. Treatment was instituted under sodium pentathol. Emo- 
tional release of his feelings over killing of the enemy was obtained and 
the following day his hearing was normal. 

Hyperacuteness of hearing (auditory hyperesthesia) presents some 
very interesting paradoxes. Slight sounds or noises are usually sensed 
as very loud. They may even cause discomfort and pain. We usually 
speak of these patients as having unusual ability to hear weak intensi- 
ties of sound. Hurst (92) tested the power of hearing accurately in 
one patient. He found that sounds could be heard at a distance four 
times as great as in the case of the average individual. This would 
mean that the hearing of the patient was sixteen times greater than the 
average. The patient could hear sentences whispered in the opposite 
corner of a large room which were inaudible to people in the center of 


the room. Administration of 100 grains of bromide per day, which is 
a very large dose, and plugging of the ears had very little effect. The 
hyperacusis was carried over into sleep. Hurst's explanations are 
theoretical and not well founded neurologically, since he assumes that 
hyperesthesia is due to some fixation of the synaptic connections of 
the auditory pathway. In all cases of hyperacuity it would be desirable 
to make some tests to determine whether the threshold changes. Some 
individuals may have a neural system so predisposed through inheritable 
factors that hyperacuity has no relation to any neurological change or 
disorder. In other individuals, there may be an emotional factor load- 
ing the circulatory system with one of the endocrine products which 
causes increased neural irritability of the auditory system. If the latter 
condition is true, then the hyperacuity should be reduced by clearing 
up the emotional factors. In these patients there seems to be some 
discrepancy between the subjective sensation of sound and the actual 
intensity of the physical stimulus. Meningitis or strychnine poisoning 
will produce phenomena akin to those experienced by the functional 

The diagnosis and treatment of these auditory defects from a psycholog- 
ical viewpoint is most difficult, since any physiological disturbance such 
as that accompanying a head cold, may furnish an actual basis for the 
sensations. With the disappearance of the organic factor the akoasma 
may still persist. 

Priest (93) has summarized the tests that have been developed for- 
unilateral deafness and malingering. These are especially useful in 
separating organic from functional cases. A description of such tests 
would be too lengthy for inclusion here. 

In our preceding discussion, we have pointed out various factors that 
influence auditory acuity, mentioning, among other factors, fatigue 
and muscle tonus. Travis (94) and Bartlett (95) have investigated 
the influence of reverie on auditory acuity as a means of diagnosing 
some of the various types of mental disorder. They proceeded on the 
theory that in certain types of mental illness, increased muscle tonus 
occurred, whereas in other types decreased tonus was encountered, and 
that the condition of muscle tonus was best brought out in reverie. 
Psychoneurotics are supposed to respond more readily to suggestions 
of daydreaming and reverie, while schizophrenic cases are supposed 
to react negatively. In reverie, we might encounter relaxation and 
lowered muscle tonus which in turn influences auditory acuity. Travis 
claimed almost 100 per cent efficiency in diagnosis by this method. 


Bartlett, on the contrary, did not corroborate the findings of Travis and 
points out numerous sources of possible error in Travis interpretations. 

In summarizing the psychological effects of deafness, a quotation 
from an article by Solomon (96) is very appropriate. 

"In the actual symptoms [of adjustment], themselves, deaf children 
do not differ from other children who show emotional disturbances. 
The manifestations may be of the nature either of withdrawal or of 
aggression. The withdrawn, submissive child may show anxieties, 
shyness, apathy, enuresis, nail biting, masturbation, tics, or other 
symptoms of a similar nature. The aggressive child, on the other 
hand, may exhibit such symptoms as temper outbursts, stubbornness, 
fighting, fire setting, lying, and stealing, or may present behavior of an 
attention-getting nature, such as clowning, grimacing, and so on. 

As the deaf child grows older, he develops less and less ability to fight 
off his feelings of inadequacy. The problem is always with him. There 
is no shaking off the handicap. As an adult, he arrives at the conclusion 
that only hearing people are happy. It is then that his spirits become 
low. A feeling of depression is quite common in deaf people. Indeed, 
this feeling of depression may lead to thought of suicide and often times 
to actual attempts in this direction. 

These feelings of inadequacy usually lead to a decided overestimation 
of the consequences of deafness. The deaf individual considers himself 
an inferior person. As we have said, he suffers from the feeling that 
his body is not intact. These attitudes reflect themselves in self- 
imposed isolation from social contacts, especially those with hearing 
individuals. Job-hunting becomes an almost insurmountable difficulty. 

The most noteworthy character trait of deaf persons is suspiciousness. 
If a hearing person were to be in a room where everybody was busily 
engaged in talking a foreign language he did not understand, he would 
naturally wonder whether he was being talked about. This suspicion 
is chronic in the deaf. It is a well-known concept in psychiatry that 
anxiety is produced when one is confronted with unknown dangers. 
The deaf person is habitually confronted with the phenomenon of 
facing the great unknown. Of course, the hearing person knows that 
most of what is said around him is not worth hearing anyhow, but the 
deaf person always thinks that he is missing something. 

Suspiciousness fostered by the productive phantasy world of the deaf 
produces the paranoid personality. These paranoid ideas may so 
completely overwhelm the individual as actually to produce a psychotic 
picture. It is not surprising to learn that it is estimated that 6 times 


as many deaf persons as hearing persons, in proportion to their relative 
numbers in the population, develop psychoses that require hospi- 


The cutaneous disorders include the sensations arising from the re- 
ceptors located in the skin, subcutaneous tissue, and the mucous mem- 
brane of the bodily orifices. The cell bodies of these receptors are 
situated in the spinal ganglia or other ganglia close to the brain stem. 






pacssuae - PAIH 


[Ml* INI 

FIG. 12. Typical spinal nerve. (Reprinted by permission from William Keiller, Nerve 
Tracts of the Brain and Spinal Cord, 1927, fig. 99, p. 381. The Macmillan Co.) 

A chain of neurons similar to those in vision and audition is not found. 
In figure 12, the cell body is represented in the dorsal root of the spinal 
ganglion. In this classification (see Dunlap's table) belong the haptic, 
baresthetic, thalpotic, rhigotic, gargalesthetic, the algetic or algesic 
and possibly the palmesthetic senses. The recognition of separate 
receptors for each of these senses has come about largely through the 
study of abnormal conditions. Cases have been found in which there 
is a loss of all varieties of cutaneous sensations; others have been found 
in which only the thalpotic or pain (algesic) sense is lacking. In fact, 



any combination of sensations may be destroyed. In addition to the 
studies of abnormal cases. Head (97), Boring (98), and more recently 
Lanier (99) have shown experimentally by sectioning a nerve fiber or 
by the infiltration of alcohol into the fiber that separate receptors func- 
tion for various kinds of physical stimuli. These receptors are dis- 
tributed over a much greater body surface than are the receptors for 
vision and audition; consequently disorders arising through injury to 
the nerve fibers are more likely to occur. Since the nature of their 
distribution and action is not so well known by the general public, 
bizarre functional disturbances result. All of the sensations of the 

FIG. 13. Loss of cutaneous sensibility: black portion, actual area of a case with complete 
cutaneous analgesia; shaded area represents a typical case of hysterical insensibility. Head, 
H.: Studies i n Neurology, Oxford University Press, 1920^.427. 

dermal group are subject to functional disorders which may cause a 
decrease or increase in sensitivity. The ones less frequently reported 
as affected are the sensations arising from the palmesthetic and bares- 
thetic senses. This may be expected since the majority of people do 
not realize that they possess receptors for stimuli of vibration and 
pressure. It is not implied that most people do not have these sensa- 
tions, but simply that they are not recognized as separate forms of sensa- 
tion. The explanation of these functional disorders is similar to the 
explanation of functional disorders of the other special senses. The 
vibration and pressure senses are less susceptible to accidental lesion 
since they are situated in the deeper layers of the skin and in the muscles 
and tendons. Collins, Zilinsky, and Boas (100) have discovered that 



diabetics are prone to impaired sense of vibration. In cases associated 
with or without peripheral neuritis, 90 per cent had impairment in the 
upper extremities while 98 per cent had impairment in the lower ex- 
tremities. The organic possibilities are not so varied since the sensory 
organs are less complicated. Any lesion of the peripheral nervous 
system, of the spinal cord, or of the brain is sufficient to cause a total or 
partial loss of sensation. The regional distribution of the loss will be 

FIG. 14. Loss of cutaneous sensibility: black portion, insensitive area caused by injury 
to the circumflex, the ulnar and the internal cutaneous nerves; shaded area represent as 
typical case of hysterical insensibility. Head, H. : Studies in Neurology, Oxford university 
Press, 1920, p. 120. 

determined by the locus of the lesion. Figures 13 and 14 show the 
actual loss of sensation following neural destruction. In these figures 
losses that might be expected from functional disorders are presented 
schematically. The technical names for total loss of sensation are given 
in the table of the modal senses. Functional anesthesia or loss of sense 
of touch can be detected more readily than the other forms of functional 
cutaneous loss. The insensitive area changes and varies from day to 
day, although at any given time the area may be plotted by means of 


The method of Bruesch and Richter (101) for detecting lesions and 
mapping cutaneous distribution of peripheral nerves may be important 
in working with certain kinds of patients. They found that disturbances 
in sweat secretion in rhesus monkeys following transection of peripheral 
nerves caused an increase in skin resistance to passage of electrical 
current. The borders of such an area of altered conductivity show a 
general correspondence to the region of cutaneous supply of the severed 

Another criterion by which it may be identified is that it does not 
conform to the anatomical distribution of the neural fibers, resulting in 
"stocking anesthesia," "glove anesthesia," anesthesia of an arm, one 
or both legs, or anesthesia of the head. The last three may be caused 
by an organic lesion. The loss of sensation of the genitals rarely occurs 
in functional disorders. In contrast with the functional losses, organic 
losses are caused by poliomyelitis, myelitis, arterio- or multiple sclerosis, 
syphilitic infection or tubercular infection which may attack any por- 
tion of the spinal ganglion or the cord. The amount of loss will depend 
upon the extent of the area as well as the position of the lesion involved. 
The loss of cutaneous sensation may be of diagnostic value in detecting 
tabes dorsalis, a syphilitic lesion involving the dorsal nerve root, before 
the onset of locomotor ataxia. 

The deeper reflexes are usually intact where organic destruction has 
not taken place and these serve in distinguishing between functional 
and organic disorders. 

Hyperesthesia is due to increased sensory or neural irritability. All 
of the sensations may be affected by this hyper-irritability. The names 
for these increases may be derived by adding the prefix hyper to the 
names of the modal senses, for example, hyper- algesia, hyper-rhigosia 
and hyper-gargalesthesia. 

Hyperesthesia may be caused by various organic conditions, such as 
meningitis, various stimulants and certain toxins. In some instances, 
the hyperesthesia is a referred condition. For example, an inflamed 
nerve fiber entering a ganglion will cause impulses arising from other 
nerve fibers entering the same ganglion to be perceived as painful, 
although the areas in which the fibers originate are perfectly normal. 
An inflammatory condition produced by exposure of a dental nerve to 
the air may, through the constant activity of its afferent impulses, cause 
afferent impulses from the nerves of sound teeth to be interpreted as 
painful. A clinical example of hyperesthesia is found in the condition 
known as dermographia (see figure 15). Any slight pressure on the skin 



with the finger nail or blunt instrument causes a welt to arise which 
may persist for a considerable period of time. It is common in cases 
of vasomotor ataxia and is sometimes found in hysteria. 

A few studies dealing with the thresholds of the cutaneous senses of 
disordered persons have been made. Hunt (102) in his survey of psy- 
chological experiments with disordered persons discusses these studies. 

FIG. 15. The letters were traced lightly on the back of a 24 year old male subject with 
a blunt wooden stylus. The picture was taken 30 seconds after the impression. 

In general, the differences in threshold for electrical stimulation among 
the various groups of psychopathic individuals are unreliable as a diag- 
nostic technique for either separating the groups or for differentiating 
them from normal people. Two point discrimination, determined on 
relatively few cases, shows that there is no clear demarcation between 
the normal and abnormal subjects, although the investigators have 
brought out certain specific trends. 


The perversions of the cutaneous senses consist primarily in the 
arousal of sensations without any adequate physical stimulus, the false 
localization of the application of the stimulus and the false interpreta- 
tion of the type of stimulus applied. These sensations consist of itch- 
ing, boring, burning, crawling, and so forth. Among the first group of 
sensations which have been listed are those encountered in the hallucina- 
tions of drug addicts. In some forms of the addiction, the hallucinations 
are chiefly of a visual and auditory nature, while in other forms of drug 
addiction, cutaneous hallucinations play a decided role. The disorders 
of localization usually referred to as dyschiasia involve nonpunctiform 
localization, sensations localized simultaneously on the opposite sides 
of the body, and sensations localized contralaterally or on the opposite 
side. The other forms of perversion of sensation include extremely 
unpleasant sensations which are unnatural or unusual. These are called 
phrictopathic sensations. Pathologically, these are produced by a 
partial lesion of the sensory conducting paths. If no lesion can be 
determined, they must be assumed to be functional in origin. 

While functional disorders give rise to sensations which may seem to 
originate in disordered sense organs, the locus of the difficulty is usually 
in the central processes themselves. It might be useful, however, to 
point out some skin disorders of a psychosomatic nature. 

Dunbar (103), and Weiss and English (104) have elaborate discus- 
sions of these disorders. Since the disorders are not strictly of sensory 
origin our discussion will be limited at this point. Among the skin 
manifestations that may be due to psychosomatic difficulties are vesica- 
tion, herpes, gangrene, edema, spontaneous hemorrhage, pruritis, urti- 
caria, eczema, psoriasis, lichen planus, verrucae, and anomalies of 
pigmentation. The psychosomatically engendered disorders are usually 
encountered in psychoneurotics, and MacKenna (105) has attempted 
to show the relationships which exist between personality types and 
kinds of skin disorders encountered. He suggests that the relationship 
is probably as follows: 

Low intelligence Hysterical make-up Narcissistic make-up Gross anxiety states Obsessional make-up 

Lesions due to Self infliction Exudative der- Excoriated Lichenification 

parasitic in- and irrita- matoses Hyperidrosis Prurigo simplex 

festation tion lesions Pompholyx Pruritis ani 

Septic lesions Rosacea Pruritis vulvae 

MacKenna believes that individuals of low intelligence run more risk 
of contracting ectodermal parasites since their hygiene is usually poor. 
When infestation occurs, there is not as much mental discomfort, hence 


a delay in seeking treatment. This delay gives rise to secondary com- 
plications such as septic lesions. Hysterics use their illness for obtaining 
sympathy or privileges and are susceptible to areas of local anasthesia. 
These factors give rise to self-mutilation and self-irritation lesions. 
The obsessional patient is assumed to be of a high intellectual make-up, 
tense, restless, overconscientious, preoccupied with cleanliness, order 
and routine, and he tends to develop to a large extent the disorders listed 
above. In contrast, in a group of patients with rosacea, it was found 
that 22 per cent had abnormal degrees of social anxiety; 42 per cent had 
long histories of sexual stress; 26 per cent had acute psychological trauma. 
The narcissistic individual is self-centered and self-absorbed. He has a 
deep conviction of inadequacy and possesses infantile psychical features. 
MacKenna believes that individuals with this type of personality de- 
velop exudative dermatoses. The following case history sets forth the 
dynamic approach held by MacKenna: 2 

"The patient tends to be of the conceited type, with an apparent 
ease of social manner and a facility for making personal contacts. He 
wears a uniform like a popinjay as an outward symbol of his awe- 
inspiring personality. Then under service discipline, he slowly or quickly 
learns that a uniform is designed for much more than personal adorn- 
ment: a battle dress is a dress for battle, and to train for battle a high 
standard of personal efficiency and knowledge is required. He finds 
that he is being outstripped in learning by his companions; he begins 
to feel inadequate; deep down within him he may realize that for all his 
bravado, battle, woundings, and sudden death are more than he can 
face. His feeling of inadequacy changes to a feeling of guilt, for sooner 
or later he will mentally let down his comrades: he, who posed as a 
tough soldier, the envied of the unit and the idol of women folk, will 
fail and will be debunked and shamed before his fellow men and women. 

"Now throughout the years of his pride, his personal appearance was 
the focus of his self-esteem, and because he has concentrated on the 
importance of his physical beauty, it is his skin that nature selects as 
the tissue in which the visible signs of deep mental conflict became 

The etiology of many skin disorders accoring to those psychosomatic- 
ally inclined is to be found in strong emotional experiences. These 
emotional experiences may result in "conditioned reactions" of the 
vasomotor system as well as in "conditioned changes" in biochemical 
activities of the body which in turn involve the apearance of the disorder. 

2 MacKenna, R. M. B. Reprinted by permission of Lancet, 1944, 247, 679-681. 


The various skin disorders respond to a variety of pharmacological 
treatments; some, however, do not. It is the claim of psychotherapists 
that many of these disorders will yield to psychotherapy, particularly 
analytic or suggestive therapy. There are very few statistical data 
which can be used to evaluate the results of these therapeutic techniques 
although there are numerous reports of treatment of a few cases by 
various therapists. Bloch (106) has attempted to systematically evalu- 
ate the treatment of warts (verrucae) by suggestion. The claims of 
success vary from about 25 per cent to 88 per cent, depending upon the 
therapist and type of verrucae treated. 

Rothman (107) has discussed the interrelation between pharmacolo- 
gical therapy and psychotherapy, or at least has theorized why one or 
the other or both approaches may relieve these disorders. He points 
out that the reactions which take place in the skin are controlled es- 
sentially by the autonomic nervous system which controls (a) the pilo- 
motor muscles involved in erection of hair follicles, (b) the activity 
of the sweat glands, (c) vasomotor reactivity, and (d) the secretions of 
the sebaceous glands. The reactions are influenced by strong emotions 
which may cause the activities directly or secondarily through the libera- 
tion of endocrine products which produce the reactions. The bio- 
chemical substances may pave the way or furnish a fertile soil for the 
development of fungus infections or herpes simplex when the individual 
is a carrier of the latter virus. Chemical therapy such as the barbi- 
turates would reduce the sensitivity of autonomic response or removal of 
the emotional elements would accomplish a similar purpose, hence either 
the endocrine output would be lessened or the reaction to it would be 

The foregoing general survey presents a partial picture of the dysfunc- 
tions related to the dermal senses. Additional consideration needs to 
be given to certain of the dermal senses since the receptor systems are 
located in areas not strictly dermal. Perhaps the most important of 
these senses is that of pain. 

Whether pain is a normal or abnormal phenomenon is open to argu- 
ment. Pain sensations may be considered normal when the organism 
is subjected to certain kinds of stimuli; nevertheless when the sensations 
become too intense or when they cannot be held in abeyance by normal 
amounts of analgesics they may be said to be abnormal. Since pain 
is one of the ways in which the organism protects itself and since the 
control of pain is a very difficult problem, we shall devote considerable 
discussion to this topic. 

Pain may arise from conditions existing in almost any part of the 


body; viscera, skin, bones, glands, blood vessels, and possibly nerve 
tissue itself. There are a variety of stimuli that will arouse painful 
sensations when they are of sufficient intensity or when repeated at 
appropriate frequencies. Pain may be aroused by pressure, heat, cold, 
electricity, and stretching of tissues. It may be local or referred in 
nature; it may be organic or functional in origin; and it is distributed 
antomically over all parts of the body. The intensity of pain can be in 
part estimated in a number of ways. The psychogalvanic reflex, blood 
pressure elevation, condition of motor reflexes, vasomotor changes, 
dilatation of the pupil, respiratory change, and in extreme conditions, 
by equilibrium loss, by trophic changes, and by elevation of temperature. 
The pharmacologists utilize as a scale the amounts of various drugs 
necessary to overcome painful sensations. It is difficult to set up a 
single classificatory system that is applicable to pain. A system based 
in part on the organic structure, such as bones, circulatory system, or 
skin tissue, might be employed but this system is inadequate since pain 
is usually localized in some particular part of the body. Regional 
tabulation therefore seems more appropriate, although not entirely 
adequate since pain may originate in areas other than those in which 
it is localized. The system adopted in table 9 is therefore a combina- 
tion of both approaches and there is a certain amount of overlapping. 

It is fairly obvious that pain sensations arise because of numerous 
body conditions and from different causes. There are certain kinds of 
pain that are quite persistent and do not respond readily to ordinary 
analgesics; hence the continuous search for better pain controlling drugs 
and new surgical means of alleviating such conditions. A few of the 
specific types of pain that do not yield readily to control are, trigeminal 
neuralgia, migraine, phantom limb pains, certain kinds of dysmenor- 
rhea, pains associated with carcinoma, and pains associated with some 
lesions of the spinal cord. While all of these pains can be assuaged 
with numerous drugs, it is not always feasible in therapy to use drugs in 
sufficient quantity to permanently inhibit the pain because of the 
depressing and deleterious effects of the drugs on other organs and func- 
tions of the body. 

As a result of these difficulties, cutting of the afferent or sensory 
nerves has been developed as a procedure. This method proves effective 
in the relief of pain for many patients but is not effective in some pa- 
tients and cannot be applied for the relief of some kinds of pain. In the 
volume entitled, Pain, edited by Wolff, Gasser, and Hinsey (108), a 
comprehensive survey of the work on pain with reference to the neuro- 




i . Head and neural structures 
A. Brain and brain stem 

B. Spinal cord 

C. Nerve terminals and 


2. Muscular tissue (general) 

3. Back 

4. Neck (including pharynx 

and larynx) 

5. Chest 

6. Abdomen 

7. Rectum 

8. Limbs 

9. Eye 

10. Ear 

11. Nose 

12. Liver, gall bladder 

13. Pancreas 

Infectious diseases, tumors, abscesses, hydrocephalus, 
syphilis, changes in blood volume, aneurysm, anemia, 
alcohol, neurasthenia, hysteria 

Hemorrhage, trauma, tumors, meningitis, poliomyelitis, 
syringomyelia, tabes dorsalis, neurasthenia, hysteria 

Influenza, malaria, gout, nephritis, diabetes, syphilis, 
gonorrhea, small pox, copper, lead, arsenic, alcohol, 
mercury, trauma, tumors, hernia, misplaced verte- 
brae, etc. 

Tumor, trauma, edema, hemorrhage, myositis ossi- 
ficans, trichinosis 

Sprain, fatigue, tuberculosis, caries, leukemia, dis- 
location of spine, involvement of pleura of lungs, heart 
and aorta, various disorders of viscera and genito- 
urinary tract, pregnancy 

Diptheria, influenza, tuberculosis, ulcers, leuetic ulcers, 
carcinoma, thyroiditis, toothache 

Disease of bones of chest, mediastinal inflammation, 
aortic aneurysm, angina pectoris, other coronary 
diseases, bronchitis, pneumonia, pleurisy, carcinoma. 
May be associated with menstruation, pregnancy, 
and ovarian disease. 

Skin lesions of erysipelas, herpes; muscular wall in- 
flammation, cysts and tumors; peritoneal inflam- 
mation, tuberculous tumors, adhesions, hernia; 
stomach, intestines and appendix pains may be caused 
by gastritis, hemorrhage, ulcer perforation, carcinoma, 
obstruction, pyloric stenosis 

Obstruction, tumors, hemorrhoids, ulcers, constipation, 

Circulation disturbances, flat feet, tubercular infection 
of joints, bursitis, traumatism of bones, osteomyelitis, 
leukemias, sarcoma and carcinoma of bones, osteitis 
deformans, rheumatism, thrombosis, phlebitis, vari- 
cose veins 

Herpes zoster, edema, tumor, empyema of sinus, oph- 
thalmoplegic migraine, corneal erosion, photophobia, 
iritis, syphilis, gonorrhea, scleritis, glaucoma, neuras- 

Furuncle, otitis media, abscess, tumors, mastoiditis, 
pressure changes 

Nasal polypi, hypertrophies, tumors, inflammation, 
sinus inflammation 

Hepatitis, carcinoma, cysts, tropical abscesses, cir- 
rhosis, syphilis, gall stones 

Inflammations, hemorrhage, calculi, cysts, carcinoma 


TABLE 9 Continued 



14. Spleen 

15. Kidneys 

1 6. Ureter 

17. Bcadder 

1 8. Male genitalia 

19. Female genitalia 

Inflammation, displacement, gumma, hemorrhage, 

cysts, tumors 
Renal tuberculosis, inflammation, rupture, growths, 

pyelitis, calculi, obstruction 
Caruncles, calculi, rupture, inflammation 
Cystitis, tuberculosis, calculi, rupture, dystension, 

Congestio. gonorrhea, syphilis, nonspecific infections, 

hypertrophy or tumors of prostate, tuberculosis 
Dysmcrorrhea organic or functional, displaced uterus, 

normal menstruation, septic infections, gonorrhea, 

syphilis, endometritis, tumors and growths, pregnancy, 

childbirth, abscesses of vagina 

logical involvements is presented. Some examples of controlling pain 
by nerve block or nerve section will illustrate the general results ob- 

Injection of alcohol or novocaine produces very satisfactory results in 
controlling pain of angina pectoris, coronary infarction, or aneurysm 
of the aorta. Similarly, if the upper thoracic sympathetic ganglia or 
their rami are destroyed, relief will be afforded (White, 109). Weiss and 
Davis (no) overcame referred pain in the skin which arose from various 
diseases such as angina pectoris, gastric ulcer, appendicitis, and ne- 
phritis by local anesthesia of the abdominal wall. Figure 16 illustrates 
the neurological mechanism by which referred pain may come into 

Not all referred pain follows similar chains of neurons. In the case of 
phantom limb pain, the neurological scheme is probably that shown in 
figure 17. Ewalt, Randall and Morris (in) review the theories for 
phantom limb pain. These include the theory that the painful sensa- 
tions are due to neuroma at the nerve stump; impaired circulation at the 
nerve stump and muscle spasms that pinch the nerve stump. They 
believe that the phenomena are associated with psychopathology since 
phantom limb types of pain are not encountered in breast and genital 
amputations. They contend also that Pisetsky's (112) results from 
electric shock treatment of phantom limb pains confirm their belief. 
The electric shock influences the psychopathology and in turn abolishes 
the phantom limb pain. Eldhart's (113) detailed description of the 


6 9 

circumstances under which phantom limb pain is encountered is quite 
interesting. Twenty-six years after an amputation of ringers and part 
of a shoulder, a patient still experienced pain in the amputated members. 
He kept a record of the circumstances under which pain was aroused and 
found that emotional experiences were intimately related. Emotion 
of anger evoked pain 50 per cent of times; fear or happiness, no per cent 


Somotic Afferent 


Viscerol Afferent Fiber 

Phrenic Nerve 


FIG. 16. Referred pain. The diagram indicates that visceral sensations, carried by 
impulses in the phrenic nerve, enter the spinal cord at the fourth cervical level, in as- 
sociation with somatic sensations from the shoulder region. The visceral impulses en- 
tering the posterior horn may so lower the threshold of the cells located there that very 
slight stimuli for somatic sensation in the shoulder, normally subthreshold, are now ef- 
fective, and the shoulder is perceived as painful. 

of times; sorrow and worry 90 per cent of times; and excitement and 
anger followed by depression 100 per cent of times. These facts point 
very strongly towards psychological factors as definite contributing 

Referred pain may be difficult to overcome because of the problems of 
determining the underlying seat of the stimulus. Most of these con- 
ditions will yield however to analgesics, surgery, or nerve block, when 
the neurological networks involved are ascertained. Referred pain 


may be intractible just as pathological conditions may produce pain 
that is intractible. Methods of dealing with intractible pain are limited, 
since by definition we are dealing with pain that does not respond readily 
to analgesics. Some methods that have proved effective are nerve 

Ulnor Nerve 

Radial Nerve 
Median Nerve 


FIG. 17. Phantom limb pain. The diagram indicates the distribution of a few of the 
nerves in the arm. Nervous impulses originally arising at points A and B were trans- 
mitted over trunk C. The formation of neuroma or the pressure of scar tissue at the 
point of amputation may cause the impulse to be generated at point C. The impulse 
upon reaching the brain is interpreted as arising in the areas A and B. 

infiltration, neurectomy, lobotomy, and hypnosis. Freeman and Watts 
(114), Van Wagenon (115), and White (116) have demonstrated the 
effectiveness of the surgical approach by the use of lobotomy or by 
excision of cortical tissue. These techniques have controlled phantom 
limb pain and pain arising from carcinoma which did not respond to 
previous types of neurectomy. Hunter and Rolf (117), and Dorcus and 


7 1 

Kirkner (118) have reported on the control of intractible pain by hyp- 
nosis. Two types of patients were at least partially amenable to this 
type of therapy. Dysemenorrhea patients and paraplegics with spinal 
damage have been able to hold pain in abeyance either entirely or in 
part. The following case history (117) shows the effectiveness of the 
control in dysemenorrhea: 3 

Mrs. C. J., aged 38 years, requested a panhysterectomy. All previous treatment had 
given no relief. She had had no preconceived complexes in regard to menstruation. 
However, her first menstruation was marked by premenstrual tension. After eight hours 
of suffering and bleeding she revealed her embarrassing condition to her mother. With 
each succeeding period the girl's suffering grew worse until chills, syncope, and uncontrol- 
lable nausea and vomiting accompanied all periods. The usual home remedies and 
surgical dilatations of the cervix were tried with indifferent success. Marriage and 
pregnancy gave no relief. Presacral neurectomy was performed without relief. How- 
ever, a succeeding pregnancy was accompanied by several episodes of painless contractions 
with bleeding, and was terminated in a precipitate delivery free of pain, demonstrating the 
sympathetic nerves had been interrupted. This was a marked contrast to her previous 
deliveries. With return of menstruation, the original intense dysmenorrhea symptoms 
reappeared, preceded each time by a week of nervous tension and anticipation, chills, 
syncope, nausea and vomiting, and bed for three days. 

Through partial hypnosis by Dr. Dorcus her symptoms were greatly relieved for two 
periods, and the patient was able to carry on her household duties for the first time. 
Estrogen was then given to suppress ovulation, and the next period was so relieved she 
came to the office to report her appreciation. The next period was preceded by a painless 
diagnostic currettage, and secretory endometrium was found. This period was more 
painful. Restriction of sodium and the administration of chloride was tried and gave 
some relief at the following period. At present, the patient feels greatly relieved and will 
seek no further help if this status can be maintained. Result: Partial relief by hypncsis; 
definite relief by suppression of ovulation. 

The paraplegics respond only in part to treatment by hypnosis. 
However, in these cases there is definitely a reduction in requests for 
analgesics when the therapy is applied. 

The treatment of ordinary pain by hypnosis is presented in part in the 
chapter on "Sleep, Dreams and Hypnosis." We should like however 
to refer to the work of Kroger and De Lee (119) on the use of hypnosis 
in managing the pain of childbirth. These workers have been able to 
inhibit normal childbirth pains in a fairly large percentage of deliveries. 

Evidence from numerous sources indicates that pain arising from 
many causes can be controlled by hypnosis, including teeth extraction, 
operations, headaches, and pathological conditions. One has to be 
extremely cautious in suppressing pain since the condition giving rise 

3 Hunter and Rolf. Reprinted by permission of Amjer. J. Obstet. and Gynec., 1947, 
53, 121-131. 


to the pain may be of a serious nature and the patient would thus tend 
to ignore the warning signals of nature. 

We should mention that the pain threshold in normal subjects can be 
raised as much as 30 per cent by placebos, by distraction, and by hyp- 
nosis, according to Wolff and Goodell (120). Neurotics seem to have a 
somewhat lower pain threshold as has been shown by Haman (121). 
Chapman, Finesinger, Jones and Cobb (122) disagree in part with 
Hainan's findings. They found no difference between psychoneurotics 
and normals in amount of heat required for perception of pain. They 
felt, however, that a motor withdrawal or wincing takes place among 
the psychoneurotics with significantly less stimulation than that required 
to produce a similar reaction in "normals". 


Disorders of certain other of the senses have not thus far been men- 
tioned. These have been purposely neglected since they are not of as 
great importance to the welfare of the organism. This is certainly 
true of the olfactory, gustatory and palmesthetic senses. The disorders 
of the static (vestibular sense) and kinesthetic senses, however, may be 
of as great importance for the protection of the organism as the special 
senses which have been taken up in detail. 

It is extremely difficult to discuss the olfactory and gustatory senses 
separately since they are somewhat complementary. Many of the 
sensations which we are accustomed to describe as gustatory are actually 
olfactory. Similarly both senses have tactile components apart from 
the real gustatory and olfactory sensations, and there is a constant 
physiologic variation in their acuity. In addition to the physiologic 
variations that might be called normal, there are a number of conditions 
that may be called pathologic. The sensations may be exaggerated; 
they may be lessened; they may be absent; or they may be perverted. 
There may be a loss of sensation for one particular kind of odor or taste 
substance, or there may be a uniform loss for all qualities of these senses. 
In the case of olfaction, the loss may be unilateral or bilateral. Elsberg 
(123) and his associates have been particularly interested in the effects 
of various odorous substances in relation to the neuro-pathology of the 
brain. Elsberg and Spotnitz (124) found that, of 115 patients with 
convulsive seizures, 50 per cent had impairment of the sense of smell. 

The most common form of temporary disturbance of these senses is 
a hypo-acuteness from inflammation of the mucous membranes. Like- 


wise, adaptation to a particular odor or taste substance reduces sensi- 
tivity for those particular stimuli. This latter example is recognized 
as a normal function of the receptors. Fatigue has been suggested as 
the cause, but this is improbable since the receptors function adequately 
with a slight change in stimulation and without rest Hyperesthesia 
is frequent in people with vitiligo (piebald or irregular skin pigmenta- 
tion) and in albinos. Vapors of sulphuric and fluoric acid; fumes from 
rubber, chloroform, and ether; and morphine and cocaine may affect 
the sense of smell adversely. Prolonged exposure may actually cause 
a permanent loss. Hyperesthesia is manifested normally in both ol- 
f action and gustation by contrast of qualities. A sweet orange tastes 
sour by contrast after saccharine has been placed in the mouth. The 
perversions may be of any quality. Sweet may be perceived as sour; 
salt may be perceived as bitter and the odor of violets may be perceived 
as some disgusting odor. 

Aguesia for a bitter drug, known as phenyl-thio-carbamide was 
originally believed to be an inherited defect. Reports indicated that 
35 per cent of the people were unable to taste this substance, and if both 
parents had the defect, the children rather uniformly possessed it. 
This conclusion needs to be interpreted very cautiously since the ex- 
perimenters did not take into account threshold differences. Many 
people who could not taste a given concentration were classed as 
aguesic for the substance. Hutt (125) has recently encountered hyper- 
sensitivity to phenolthio-carbamide which seems to run in families. 
Miller (126) found that aguesia for the substance may be a fairly good 
indicator of a pre-diabetic state. The rate of infant death was 8.3 per 
cent for children of prediabetic women as compared with a 2.0 per cent 
for the non-diabetic group. All of the prediabetic mothers were non- 
diabetic at the time of delivery. One hundred per cent of the pre- 
diabetic women developed diabetes later, but none before the age of 

A complete discussion of the kinesthetic sense would involve almost 
the whole response mechanism. Many of the more complex adjust- 
ments of the organism such as writing, walking, talking and thinking 
depend to a certain extent upon kinesthesis. Since certain of these 
topics will need extended elaboration only generalizations will be pre- 
sented at this point. 

The kinesthetic or movement sense has its receptors in the deep layers 
of the various muscles of the body, the tendons and possibly the joints. 
It is closely connected with the vestibular, tactual and visual senses. 


In fact, the interrelation of these senses enables us to develop space 
perception. In speaking of the kinesthetic sense, reference is usually 
made to perception of movements such as are involved in walking, mov- 
ing the arm, or changing the body posture. Movement of the external 
eye muscles, and possibly the muscles of the middle ear are equally 

Perversions of this sense, as well as its close relation with the vestibular 
and visual senses, can be demonstrated by past pointing following rota- 
tion or caloric stimulation. A blindfolded individual, if asked to touch 
an object directly in front of him and then raise his hand in the median 
plane, will be able again to touch the object as his hand is lowered. 
Following stimulation of the type suggested above, he will be unable 
to accomplish this task. The hand will be deflected to the right or left 
depending upon the type of stimulation administered. 

Drinking of alcohol and other intoxicating beverages influences the 
movement sense. Whether these operate in a manner which prevents 
the integration of various senses or whether the symptoms manifested 
are due to a general hypo-sensitivity of the receptor systems is not 
easily determined. 

In functional perversions, directional movements in both the hori- 
zontal and vertical planes are confused. A movement to the right may 
be perceived as a movement to the left. Inability to touch a portion 
of the body such as the nose, or tip of the finger on the other hand may 
occur. These failures of localization are frequent in paretic patients. 
If the sensory pathway from a finger is severed, the subject will not 
voluntarily move that finger although the motor pathways are intact. 
If the finger is flexed by another person, movement will not be perceived. 

Hypokinesthesis and hyperkinesthesis may be of functional or organic 
origin. Movements are perceived as lessened or exaggerated. Which 
will obtain, will depend upon the type of organic defect present or the 
psychological factors involved in the functional disorder. 

Since the receptors for the kinesthetic sense are located in the effectors 
(muscles and tendons), the student encounters difficulty in compre- 
hending the relation between sensory and motor disturbances. Loss 
of muscular response may be due to a lesion in the sensory pathway, the 
cord, the brain stem, the cortex, the efferent pathway, or may be caused 
by atrophy of the muscle itself. The exact nature of the organic dis- 
turbance can be determined clinically. The situation is clearer for 
audition. The receptors are located in the basilar membrane in the 
cochlea, and the effectors are the muscles and glands of the whole body. 


The determination of whether the disorder is sensory or motor becomes 
relatively simple where audition or vision are concerned. 

Disorders of sensation of movement may be corrected through a 
process of reeducation after the psychological or organic causes are 
removed. This means that reformulation of the patient's experience of 
space perception is involved. 4 The task is slow and gradual and calls 
for considerable cooperation on the part of the patient. A synthesis 
must be made of the various sensory components. The process of 
learning would probably follow the same course of relearning to hit a 
target after having learned to hit it with prisms interposed before the 

The sensations arising from the stimulation of the semicircular canals, 
the sacculus, and the utriculus are usually attributed to the vestibular 
sense. There are, in addition, sensations derived from receptors of the 
kinesthetic sense of the eye muscles and neck muscles and sensations 
from the visceral or somatic senses which are confused with the strictly 
vestibular sensations. The responses to these stimuli are eye nystag- 
mus, changes in bodily posture, maintenance of muscular tonus, vertigo 
and nausea. The pathology of the vestibular sense may arise from 
any one of a number of factors. 

Among the symptoms of pathology of the vestibular sense may be 
listed: absence of nystagmus, continuous nystagmus, tendency for pos- 
tural changes such as carrying the head in an unnatural position, flexion 
or spasticity of various portions of the body, particularly of the homo- 
lateral variety. The actual causes of these symptoms are to be found 
in functional and organic disorders. 

De Jong (127) has prepared a summary of the recent work on nystag- 
mus and has devised a scheme for classifying the phenomena. We shall 
use his work in part as the basis of our discussion. Table 10 will be 
useful in obtaining a clearer picture. 

It would require too much space to deal with all these types of nystag- 
mus in detail. We shall try to indicate briefly the nature of the nystag- 
mus and its etiology: 

Opticokinetic nystagmus is elicited by watching a moving object such 
as a revolving striped drum; it is sometimes called railway nys- 
tagmus. Its absence is usually considered pathological and is as- 
sociated with frontal lobe lesions. 

4 For a complete picture of the development of perception, the student is advised to 
review Elements of Scientific Psychology , Chapter 12, by Knight Dunlap. 


Rotational nystagmus is elicited by rotation of subject in a chair (about 

ten times) followed by cessation. 
Thermal or caloric nystagmus is produced by injecting into the 

external meatus warm (40 C) or cold (20 C) water. 
Nystagmus is induced by galvanic stimulation when weak electrical 

current is passed through the head. 





1. Opticokinetic nystagmus 

2. Labyrinthine nystagmus 

a. Rotational nystagmus 

b. Thermal or caloric nystagmus 

c. Galvanic stimulation nystag- 


d. Compression nystagmus 

3. Reflex acoustic nystagmus 

4. Reflex sensory nystagmus 

5. Chemical or toxic nystagmus 

1. Originating in eye or its adnexa 

a. Nystagmus of optic derivation 

(1) "Ocular" nystagmus 

(2) Occupational nystagmus 

(3) Spasm mutans 

(4) Reflex nystagmus 

b. Nystagmus of neuromuscular 

(1) Paretic nystagmus 

(2) Fatigue nystagmus 

(3) Eccentric fixation 

(4) Latent fixation 

2. Originating in centers controlling 

ocular movement and equilibrium 

a. Vestibular nystagmus 

b. Cerebellar origin nystagmus 

c. "Central" origin nystagmus 

3. Miscellaneous varieties of nystagmus 

a. Toxic nystagmus 

b. Congenital nystagmus 

c. Lesions of cervical portions of 

spinal cord 

Compression nystagmus occurs when unilateral pressure is exerted on 
semi-circular canals. 

What the absence of experimentally induced nystagmus means has 
been the subject of considerable controversy. The absence of the post- 
rotation nystagmic response was considered by some otologists to be a 
sign of disorder of the vestibular mechanism. Many aviators were 
rejected at the beginning of the first world war because the duration of 
their post-rotation nystagmus was very long or very short. They later 
enlisted in foreign service and became expert aviators. The experi- 
mental findings of the psychologists working under the direction of 


Dunlap, Bentley, and Dodge have definitely exploded this notion, since 
the response lessens and disappears with repeated stimulation. This 
habituation to rotation is usually explained by a modification of the 
central nervous system similar to the modification which takes place in 
learning. Some of the early workers attributed this habituation to 
a tearing of the membranous canal. One difficulty with the theory is 
that habituation to rotary stimulation does not necessarily produce 
habituation to caloric and electrical stimulation. If responses are se- 
cured to caloric and electrical stimulation the mechanism must be 
functionally intact. The period required for normal resumption of the 
post-rotation response is somewhat in doubt, consequently no conclusion 
can be drawn about a pathological destruction on that basis. 

Variations in response to any one of the forms of induced nystagmus 
may however be indicative of pathology. Unequal nystagmus, per- 
version of a response, or dissociation of response with vertigo and past 
pointing but without nystagmus, indicate possible lesions of vestibular 
centers or their central connections. 

Reflex acoustic nystagmus results from a loud auditory stimulus. 
Gerlings and Kleyn (128) believe that acoustic stimuli penetrate 
directly to the cristae of labyrinthe when fistula is present. 
Reflex sensory nystagmus may follow stimulation of skin in neigh- 
borhood of the ear. 
Chemical or toxic nystagmus may be one of the signs of ingestion of 

barbiturates, lead, nicotine, etc. 

Ocular nystagmus is a slow irregular type of movement and is en- 
countered in individuals who have had very deficient vision since 
birth. It develops shortly after birth but does not occur in persons 
blind from birth. There is attempt on the part of the organism to 
obtain fixation which cannot be accomplished because of poor 
vision. It is observed in persons with congenital cataract, in- 
terstitial keratitis, choriore tinnitus, and great errors of refraction. 
Occupational nystagmus is believed to be a hysterical conversion 
symptom by Stern (129), and is encountered in miners, compositors, 
draftsmen, jewelers, and workers who are subjected to low illumina- 
tion and frequent eye movements. Miner's nystagmus, which is 
partly due to improper illumination, may involve any type of eye 
movement. The severity and type of movement is influenced by 
darkness, by elevation of the line of regard and by sudden move- 
ments. In 83 cases studied by Brock (130), the average time for 
onset was 23.3 months. 
Spasm mutans consists of a rhythmic nodding or rotary tremor of the 


head accompanied by a fine rapid nystagmus. It is seen in babies 
from 6 months to 2 years of age who are kept in dark surroundings. 
It ceases upon closing the eyes. 
Reflex nystagmus is present sometimes in very painful diseases of the 


Nystagmus of neuromuscular origin will be found in paretics, in 
myasthenia gravis, and in amblyopia resulting from strabismus. 
All of these conditions cause difficulty in neuromuscular adjustment 
of the eye for clear vision and the inability to maintain or obtain 
clear vision causes the nystagmic movements. 

Vestibular nystagmus is a response to stimulation or destruction of the 
labyrinthe. Pathology brought about by hemorrhage, suppuration 
due to disease, pressure changes in labyrinthe fluids, trauma of 
inner ear or vestibular sense, meningitis, neoplasm or toxins, is the 
probable cause of this kind of nystagmus. 

Cerebellar origin nystagmus develops from lesions that may be trau- 
matic, vascular, degenerative, inflammatory, or neoplastic in nature. 
Central origin nystagmus may result from lesions in the oculogyric 
centers in the frontal, occipital, or temporal lobe. Nystagmus re- 
sulting from involvement of association pathways may be en- 
countered in multiple sclerosis, hereditary ataxia, syringobulbia, and 
other causes. 
Miscellaneous varieties of nystagmus arise from cases specified in the 

preceding table. 

Various diseases of the middle ear and brain will produce continuous 
nystagmus. In these cases, there is a continuous oscillation of the eye- 
ball in either the horizontal or vertical meridian. The movement may 
also be rotary; the eye partially oscillates about its visual axis. Destruc- 
tion of one or all of the membranous canals (the nystagmus is temporary 
in this case), meningitis, multiple sclerosis and brain tumors may produce 
abnormal nystagmic responses. 

Fitzgerald and Stengell (131) using 50 unselected schizophrenics found 
that many of them gave abnormal vestibular responses similar to those 
encountered in verified lesions of the labyrinthe. Worschel and Dallen- 
bach (132) in testing deaf mutes demonstrated that pathology of the 
canals exists in 55 to 60 per cent of the cases. These findings were 
confirmed in part by histological examination and in part by the absence 
of nystagmus. Angyal and Blackman (133) in attempting to explain 
the apathy and apparent loss of muscle tonus in schizophrenics, have 
investigated the reactivity of such patients to rotational and caloric 


stimulation. Using the nystagmic response as their criterion, they found 
that certain of these patients were decidedly deficient in response, and 
postulate that the above factors may be explained on a basis of dys- 
function of the vestibular mechanism. Fearing (134) has shown that the 
sensations from the receptors in the vestibule are not absolutely neces- 
sary for orientation and maintaining posture although they ordinarily 
play an important role. He has found by removing sections of one or 
all of the membranous canals in pigeons that nystagmic head movements 
occur (these head movements in birds correspond to the eye movements 
in humans) along with marked postural changes. After a relatively 
short time, both the posture is corrected and the nystagmic head move- 
ments disappear. These results seem to dispose of the theory explaining 
the normal functioning of the semi-circular canals through a displace- 
ment of the otoliths by the endolymph in the membranous canals. 
A comparison of the functioning of the canals in humans with those in 
birds must, of course, be drawn with extreme caution. Work by 
Buchanan (135) has further demonstrated that post-rotational symptoms 
can be elicited in guinea pigs with the cerebral hemispheres and thalamus 
removed. Neither the saccadic or drift components were altered by 
decerebration passing dorsally through the superior colliculi and ver- 
tically through the mammillary body. Figures 10 and n show the 
neural connection of the sensory vestibular branch of the eighth cranial 

Very little progress has been made in the treatment of abnormal 
nystagmic conditions, although the removal of brain tumors and other 
sources of pressure has cleared up some cases. 

Another response to vestibular stimulation is vertigo, which is a feeling 
of movement or dizziness in the absence of spatial dislocation of the 
subject. Vertigo arises from many causes, and Poos (136) has sys- 
tematized some of the conditions that give rise to vertigo. 

It becomes apparent that vertigo is a complex phenomenon which may 
arise from visual, vestibular or central causes. Whatever therapy is 
indicated will depend upon the nature of the etiological factors. Eliaser 
(137) has evolved a treatment for certain kinds of vertigo which he 
believes is caused by the disparity between cerebral blood volume inflow 
and outflow. One condition in which this impairment takes place is 
arteriosclerosis. He attempted therefore to obstruct the venous return 
by appropriate placing of an elastic collar. He reports very favorable 
results on a number of cases treated in this manner. This brief dis- 
cussion is adequate to acquaint the student with the nature of the 




Ocular vertigo 
Aural vertigo 

Psychogenic vertigo 
Cortical origin vertigo 

Cerebellar origin vertigo 
Brain stem origin vertigo 

Eighth nerve origin vertigo 
Blood disease origin 

Cardiac disease origin 
Metabolic disease origin 

Respiratory tract origin 

Looking from tall building 

Blockage of eustachian tubes 

Middle ear infection 


Hyperemias or anemias of brain 

Malocclusion of jaws 

Meniere's syndrome 


Petit mal epilepsy 







Many of causes listed above 







Hypo or hyper thyroidism 

Hypo or hyper glycemia 


Disturbances of water balance 



Other drugs 

Frontal sinus infection 






problem, and he will not likely be concerned except in those cases which 
are functional in origin. 

One major type of disorder that is frequently identified with vestibular 
stimulation is nausea, although it may result from many other causes. 
We shall limit our discussion however to nausea caused by altitude or 
excitation of the vestibular sense through motion. This problem is of 
considerable magnitude when we consider the number of people travel- 
ling by plane, railroad, automobile, and in elevators. What percentage 
of the population is susceptible is difficult to say, since susceptibility 
depends upon the characteristics of the stimuli, the physical condition 
of the individual, the environment surrounding the individual, and his 
mental set toward nausea. 

Wendt et al (138), showed that wave energy or volume of the motion 
rather than its time characteristics (that is, separation of accelerations) 
is the feature revelant to motion sickness. The length of exposure to 
stimulation is an important contributing factor, since very few pilots or 
passengers have escaped nausea at some time when subjected to violent 
stimulation for a long period of time. The physical well-being of the 
individual enters into the picture. Hangovers, fatigue, constipation, 
unwise eating, or minor illnesses tend to enhance the probability of 
motion sickness. Extreme heat or cold, unpleasant odors, sight of others 
who are nauseated, and suggestions of illness will add to the probability 
of nausea. Dorcus, Mount and Kirkner (139) showed one film of an 
individual becoming nauseated while taking laboratory tests to one 
group of students, and another film of an unaffected student undergoing 
the same laboratory tests to another group of students. Both groups 
were then subjected to the same tests. About three times as many 
students became nauseated from the first group as became nauseated 
from the second group. Undoubtedly, expectancy plays a large part, 
although nausea may result even with a favorable mental set. 

Dogs, cats, frogs, and even fish seem to become seasick when subjected 
to appropriate stimuli. Sjoberg (140) has shown quite conclusively 
that the labyrinth must be intact to produce motion nausea, since dogs 
with destroyed labyrinths would not become nauseated by three hours 
of stimulation on a mechanical device. Prior to the operation this 
same device produced nausea after u to 20 minutes of stimulation. 

Jones (141) has refuted the belief that women should not pilot planes 
and possibly not drive cars during the menstrual period since they may 
be more susceptible to nausea induced by vestibular stimulation. She 
did not find any significant difference in susceptibility between men- 


strual and non-menstrual subjects on laboratory tests that induce 

Work in this area was intensified during the first world war and the 
second world war because of the number of potential pilots that had to 
be rejected because of airsickness, and the number of soldiers who be- 
came ill during small craft landing operations. It became imperative 
therefore to devise some screening technique to weed out those men 
prone to sea or air sickness, or to find some ameliorating drugs which 
would inhibit nausea. 

Various types of tests have been devised to select individuals who are 
likely to be chronically motion susceptible. These include rotary tests 
swing tests, caloric tests, drug tests, and personality tests. Wendt et 
al (142) ; Birren, Fisher, and Stormont (143) ; Birren, Stormont and Pfeif- 
fer (144) ; and Dorcus and Kirkner (145) have evolved tests having vary- 
ing degrees of efficiency. Previous histories of sickness on moving 
objects seem to be a somewhat better indicator than the generally ac- 
cepted neurotic traits and laboratory techniques in yielding fairly suc- 
cessful results for screening motion susceptible individuals. 

Numerous investigations of the effectiveness of various drugs have 
been undertaken. The work of Rolling, McArdle and Trotter (146); 
Tyler (147); and Lilienthal (148) are typical. Rolling and his as- 
sociates tested scopolamine, atropine, hyoscamine, barbiturates, am- 
phetamine, and chlorobutanol for controlling seasickness. They com- 
pared groups who had been given drugs with groups given placebos. 
They found scopolamine most effective. Tyler tested the effectiveness 
of barbiturates, neostigmin compounds, and scopolamine, employing 
15,000 subjects. He found that in one experiment when 53 per cent of 
the placebo group were sick (the degree of severity being great in 37 
per cent), the incidence of sickness was only 27 per cent in the sco- 
polamine group (the degree of severity being great in only 10 per cent 
of the subjects). Lilienthal tested a number of drugs for their efficacy 
in combating air sickness. He found that his results were comparable 
to those of the previous investigators in that scopolamine was the most 
effective deterring agent. 

An experimental investigation by Wolf (149) is difficult to interpret, 
since his findings seem to contradict the results of previous investigators. 
He irrigated the ears of subjects with cold water and obtained kymo- 
graphic records of stomach motility during the process of becoming 
nauseated. Nausea was experienced only when the stomach motility 
was inhibited. He felt therefore that drugs which cause continued 


motility prevent nausea. It is probable that spasms of the stomach 
muscles produce the nauseating effect and that barbiturates or scopol- 
amine tend to prevent spasms. 

A recent manual prepared by Van de Water and Wendt (150) gives a 
number of practical suggestions on the avoidance of motion sickness. 
They indicate that learning (conditioning) and expectation play an 
important role. The individual associates previous experience or ex- 
periences of others, odors, etc., with nausea and tends to be nauseated 
for that reason. Other suggestions for the avoidance of airsickness 

1. Making short trips at first 

2. Making initial trips in fine weather 

3. Avoiding acrobatic maneuvers 

4. Not flying until tolerance is established, and not flying when upset by hangovers, 

fatigue, constipation, unwise eating or minor illnesses 

To these may be added the further hints that: (i) the individual 
should be occupied if possible; (2) avoid reading while in motion; (3) 
sedatives may be of value if the individual does not have responsibilities 
of operation; and (4) try to avoid fear associated with the trip. 

Very little can be said about functional disturbances of the vestibular 
sense, although there is no doubt that these types of cases exist, especially 
in view of the fact that the central nervous system plays an important 
role in habituation as well as in the coordination of the visual and 
vestibular stimulation in post-rotation nystagmus. 


For the premedical student and for other students who may be further 
interested in the neurological foundations of sensory disorders, the fol- 
lowing summary of the dermal senses may be useful. Since the dermal 
senses are highly complex in their organization no more than a brief 
survey can be attempted. For those students who are interested in 
abnormal psychology as a cultural course or who are interested in it 
only in so far as it will enable them to make a better adjustment in life, 
an examination of this section may furnish a little more comprehensive 
view of the field. Lesions of sensory nerves of vision, audition, olfac- 
tion, and gustation result in rather clear cut disturbances usually with- 
out other complicating sensory losses; the cutaneous senses produce 
many marked and varied disorders dependent upon the level and ex- 
tent of the lesion. 

A complete lesion of a cutaneous peripheral nerve results in the loss 


of light touch, cold and heat between 72 and IO4F., tactile discrimina- 
tion and localization. If the lesion occurs in a mixed nerve trunk, there 
is a further loss of the temperature sense, pain and pressure (heavy 
touch). Incomplete interruption produces anomalies of sensation. 
There is generally a partial loss of sensation of various kinds and pares- 
thesia. In posterior nerve root destruction, such as occurs in syphilitic 
infection, the afferent system may become more deeply involved. If 
the lesion involves only one side, the loss will be only on one side; if 
both roots are affected, the loss will occur on both sides. The area of 
loss will be determined by the number and level of the spinal segments 
destroyed. Losses from this cause include those mentioned above and 
in addition, marked pains, loss of the palmesthetic and kinesthetic 
senses. All of the cutaneous sensations are not lost at once, but as the 
disease spreads into the cord (which occurs in tabes dorsalis), there is a 
progressive loss. Posterior nerve root destruction presents a better 
picture of localized body loss of cutaneous sensations than any other 

The sensory ascending fibers in the spinal cord and brain stem are 
involved in so many commissures, decussations, and nuclear relays that 
any simple description of the sensory loss becomes almost impossible, 
without specifying numerous points of lesion. The loss may be un- 
ilateral or bilateral; any one of a number of the cutaneous senses may be 
involved. In general, a regrouping of the fibers for the various sensa- 
tions takes place immediately after entry into the cord. Pain, thermal 
and tactile fibers terminate in the posterior horn of the cord, and a new 
set of fibers cross over to the opposite side, forming the spino-thalamic 
tracts. This holds true for all except a few tactile fibers and the fibers 
conveying the kinesthetic impulses from the deep muscle layers. These 
continue straight up the same side of the cord in the columns of Goll and 
Burdach. These columns terminate in nuclei in the medulla oblongata, 
where new fibers which are joined farther up by those from the spino- 
thalamic tracts finally enter the thalamus and sensory cortex. In 
figure 1 8 some of the pathways of the afferent system are presented. 
The higher the lesion, in general, the more likely the upper portions of 
the trunk and head will be affected. If the lesion occurs in the lower 
segments, only the region supplied by the lumbar and sacral nerves will 
show a sensory loss; lesions slightly higher may involve the thoracic 
and cervical regions as well. An upper cervical cord destruction will 
produce a sensory loss of the cutaneous senses in the face and cervical 
regions. Lower regions may be involved, depending upon the nature 


and extent of the destruction. Limited destruction of the thalamus 
affects the static, kinesthetic, algetic, haptic (rarely completely abol- 
ished), rhigotic, thalpotic, and palmesthetic senses. Both localization 
and discrimination of touch are diminished and may be abolished. 
Lesions of the sensory cortex which result from the hemorrhages of 



FIG. 1 8. Diagram spinal tracts. Sensory group. Caud.^ caudate nucleus; Cun. y nu- 
cleus cuneatus; Gra., nucleus gracilis; Fif., sensory root fifth nerve; Ant., anterior nerve 
root; Svn., spinal nerve; Spg. y spinal ganglion; Pos., posterior nerve root; A y anterior; P., 
posterior; / and ?, heat and pain; 2 and 4, muscle sensations, touch (partially). (Modi- 
fied from Lickley. Reproduced by permission from J. L. Lickley, The Nervous System. 
Longmans, Green and Co.) 

blows, wounds, or emboli do not produce complete loss of primary 
sensations. There are judgment losses, that is the inability to evaluate 
or distinguish between the relative intensity of a present stimulus with 
that of a preceding or even simultaneous stimulus. On the whole, 
cutaneous sensations are not markedly altered by cortical destruction, 
except in the above way. 



The question whether deprivation of one of the special senses causes 
the other senses to be more sensitive or acute has been discussed for a 
long time. The very early records of medicine and philosophy refer 
to the problem. The three cases which have been more directly re- 
sponsible for recent controversies are Helen Keller, Laura Bridgman 
and Marie Heurtin. These cases are especially interesting since they 
have demonstrated the ability of people who are deprived of most of 
their special senses to acquire a fairly adequate mental life. 

Helen Keller lost her hearing and sight at the age of eighteen months 
following a serious illness. As a result of these afflictions she became 
mute. Laura Bridgman and Marie Heurtin were also deaf and blind, 
the latter from birth. The former was deprived of taste and smell in 
addition. All three of these individuals through systematic education 
have developed mentally to such an extent that they possess a fairly 
good knowledge of the world about them. Their education centered 
about the sense of touch. Since they made such remarkable progress 
through this medium and since so many things are accomplished by only 
this sense, many have insisted that their tactual acuity must be very 
much exaggerated. The experimental evidence bearing on compensa- 
tion is rather meagre. Villey 5 (151) summarizes the early work. He 
states that Laura Bridgman possessed an esthesiometric tactile sensi- 
bility two or three times greater than that of normal persons. Jastrow, 
according to Villey, did not consider her tactile sensibility to be re- 
markably superior to that of a normal person. In summarizing the 
work of Griesbach and Kunz with regard to the sensitivity of the sur- 
viving senses of the blind, Villey gives the following account: 

1. Tactile discrimination for stationary objects is approximately the same for the 

blind and for those who see. 

2. Congenital blindness is likely to reduce the tactile acuity below that of the normal 


3. A strong stimulus is required for provoking a tactile sensation in the blind. 

4. Auditory acuity and localization are about equal to the normal. 

5. Olfactory sensitivity is not increased. 

Work by Renshaw (152) and his associates using seven blind children 
and four blind adults does not entirely corroborate the results reported 
above for adults. On the initial trials of tactile-kinesthetic localization, 

6 Villey's summary is taken from L'Ann6e psychologique, Vol. VI, p. 518. 


there is not a marked difference for the adults, but in the later trials, 
the blind make little or no improvement when compared with the 
seeing subjects. The seeing children acquire tactile-kinesthetic ability 
more rapidly than do the blind children. The results are given in figure 








5 e 

8 9 10 

FIG. 19. The relation between accuracy of localization and practice. Curves A^ B, C 
and D are for seeing subjects; curves E, F, G, and H are for blind subjects. The abscissa 
represents days of practice; the ordinate indicates mean error in millimeters. Seeing sub- 
jects: A y adult arm; B, adult hand; C, child's arm; D, child's hand. Blind subjects: 
E, adult arm; F, adult hand; G, child's arm; H y child's hand. (Combined diagrams from 
Renshaw, Wherry and Newlin. By permission from the J. Genetic Psychol.) 

19. In explaining the superiority of the blind adults on the initial 
trials and the inferiority of blind children on the later trials when 
compared with their respective normal groups, they propose the theory 
that dependence upon contact excitation for localizing in childhood 
becomes replaced by visual receptor function in adults. That is, as 


space perception develops, dominance shifts from the haptic to the 
visual sense. 

Dolansky (153) maintains that the blind can sense objects in their 
pathway which results in an awareness of being lightly grazed across 
the face when such objects are approached. In attempting to discover 
what senses were involved, he covered the face with card-board masks. 
Despite these masks they still had the sensations. He next plugged 
the ears with cotton and they then felt nothing. He believes that the 
sensations were derived from auditory stimulation. 

In explaining the sensations on the face, Dolansky points out that the 
blind are fearful of accidents. This fear increases when the warning 
sound is heard, and fear causes a reflex action in the skin. In states of 
fear, the muscle fibers attached to the hair follicles cause the hair to 
rise perpendicular to the surface of the skin, which gives the rustling 
or grazing sensation on the face. His results do not throw any light on 
auditory hyperesthesia of the blind since no normal subjects were em- 
ployed, but the mechanism which he postulates for explaining the un- 
usual sensations is interesting. Dallenbach (154) seems to have proved 
definitely that reflected sound waves are the means by which the blind 
avoid obstacles in their environment. He found that when the ears 
of both blind and blind-folded subjects were stopped or when an inter- 
fering sound screen was introduced artificially, the subjects were unable 
to detect a wall that they were approaching. 


Synesthesia may be defined as a secondary sensation accompanying 
an actual perception. This subjective impression is always of a differ- 
ent mode from that of the sense through which the perception has oc- 
curred. For example, "an auditory sensation may be accompanied by 
a sensation of color. When this occurs, it is referred to as colored- 
hearing or chromesthesia. Many forms of synesthesia have been re- 
ported. Almost any combination of the modal senses may be involved. 
This disorder, as well as sensory compensation may not belong strictly 
to sensory disturbances, since a study of perception and association are 
necessary for understanding their genesis. Synesthesia may be ex- 
plained on a basis of the normal process of association. An individual 
who hears one of the classics played for the first time may miss the 
interpretation of the author in which a storm is portrayed. If he is 
advised later of the composer's intent, the playing of that particular 
composition will certainly recall a storm. In colored hearing a strong 


emotional association may establish the connection between a certain 
sound and a color, so that whenever a particular sound is heard the 
sensation of a definite color is experienced. Some theorists have ex- 
plained this phenomenon on a basis of special anastomoses between the 
brain centers involved in the perception of sound and hearing; or by 
irradiation. The latter is the spread of electrical current in the neural 
tissue. It is quite similar to leakage of two electrical lines in juxta- 
position. If current flows in one line, a glow may be obtained from a 
lamp in another line even though that line is connected with no other 
battery or source. Langfeld (155) gives a summary of the work on 
synesthesia which will enable the reader to get a more comprehensive 
view of the topic. 




The human being is primarily a mechanism for response, and by means 
of response, he tries to adapt himself to the environment or to adapt 
the environment to himself. Since perception and thought are parts 
of the response process, he also perceives the environment, perceives 
himself, and thinks about both his environment and himself. It will 
be recognized that in responding to any given situation or complex 
pattern of sensory stimulation, a wide range of muscles or effectors are 
brought into action apart from those directly concerned with the spe- 
cific response. Because the effectors are involved to such a great extent 
in perception and thought, it is impossible to discuss disorders of these 
functions in later chapters, without referring to the motor disorders 
which are essential for their occurrence. It is useful to examine these 
disorders from the viewpoint of the motor processes. In our treatment 
of motor disorders, we shall include not only those disorders arising 
from conditions of the effectors themselves but also certain disorders in 
which the effectors appear to be responsible but in which disorders of 
the association processes are predominant. 

The effectors, which include the striated or voluntary muscles, the 
smooth or nonvoluntary muscles and the glands, may be the terminal 
action in complete perception, thought, or reflex activity. In the first 
group belong all the striped muscles of the body such as those of the 
arms, legs, trunk, external muscles of the eyeballs, and the vocal cords. 
Certain of the functions of the striped muscles which occur in what is 
conventionally called reflex activity appear to be nonvoluntary, since 
the response invariably occurs upon stimulation. The knee jerk 
(patellar reflex), the pupillary reflex, and the lid reflex are ordinary ex- 
amples of this kind of action. These reflexes are not invariable since 
certain of them have been modified experimentally. Volition has a 
decided effect upon the facilitation and inhibition of the knee jerk. 
The striped muscles are too numerous for individual listing, but it 
suffices to say that almost any single group or combination of muscle 
fibers may malfunction in any one of numerous ways. 



9 1 

The second group of effectors contains those muscles which are con- 
trolled chiefly by the autonomic nervous system. The muscles of the 
lungs and those of the stomach and intestines which produce peristalsis 
are of the smooth variety and on the whole nonvoluntary. The cardiac 
muscle, although having some features of striated muscle, is placed in a 
class by itself. It is usually designated nonvoluntary. 

The glands comprise the third group of effectors. These are of two 
types, duct glands and ductless glands. The major number of the former 
secrete substances into the digestive tract through openings or ducts. 
Saliva and bile arise from glands of the duct variety. This whole group of 
glands is concerned with the vegetative functions of the organism. The 
ductless glands or endocrine glands are those which secrete directly into 
the blood stream and hence their secretions are called "internal/* 
They may secrete into the lymphatic system, although this view is not 
usually held. The lymph glands themselves do not belong to the en- 
docrine group. The pituitary, thyroid, parathyroids, and the intersti- 
tial parts of the sex glands (testes and ovaries) are glands of the endo- 
crine type. The function of these glands, as well as their place in 
abnormal psychology, will be discussed in detail in later sections of the 

For a comprehension of some of the abnormalities of muscular ac- 
tivity it is necessary to understand the normal functioning of the muscles 
and their innervation. The innervation of the muscular system causes 
voluntary activity, muscle tonus, and so called reflex activity. Vol- 
untary contraction of muscles is brought about by connections from the 
motor cortex of the brain through the descending fibers of the spinal 
cord. The motor fibers in the cerebro-spinal tracts originate from cells 
in the motor cortex. As these fibers descend, there is a partial decus- 
sation of some of the fibers in the region of the medulla; others decussate 
at a lower level in the spinal cord. Ultimately, complete decussation 
occurs so that the muscles on one side of the body are controlled by 
nerve fibers which originate on the opposite side of the brain. All of 
the descending fibers are grouped in the anterior horns of the spinal 
cord. The pathways which function for muscular tonus have their 
origin (a) near the corpora quadrigemina, (b) in the red nucleus and 
(c) in the vestibular nuclei. These descend in columns designated as 
the tecto-spinal, rubro-spinal and vestibulo-spinal tracts. They ter* 
minate by branching in the anterior horns. Figure 20 shows schemat- 
ically the origin, and descending tract of the motor nerves. The fibers 
which control all varieties of muscular activity leave the spinal cord by 


the anterior root of the spinal nerves. They gradually branch as they 
spread throughout the body. 

Normal motor functioning requires two muscles operating recipro- 
cally. These are conventionally called the extensor and flexor muscles. 
The former serve the purpose illustrated by the extending or straighten- 
ing of a finger or a leg and the latter serve the purpose which is charac- 
teristically flexing or bending. The movements which can be made 


FIG. 20. Diagram spinal tracts. Motor group. //., internal capsule; Pyr., decussation 
of pyramids; Motor., motor (anterior) root spinal nerve; / to ^, corresponding tracts. 
(Modified from Lickley. Reproduced by permission from J. L. Lickley, The Nervous 
System. Longmans, Green and Co.) 

may be relatively simple and involve relatively few muscle groups or 
they may be very complex and involve a great many. There are three 
aspects of muscular response, (a) speed of movement, (b) accuracy of 
movement and (c) strength of movement. All three of these aspects 
of muscular control are subject to disorders. Laboratory methods for 
measuring muscular control have been devised and standardized. 
Speed of movement may be measured by speed of tapping or by reaction 



time; accuracy of movement by a steadiness test, coordination test, 
ataxiagraph, and so forth; strength may be measured by a dynamometer 
or ergograph. In spite of the standardization of methods of measuring 
these aspects of motor control, very few attempts have been made to 
apply the methods to abnormal subjects. Hunt (156) has reviewed the 
work of Franz, Gatewood, Boring and others on this topic. 

Disorders of movement which involve the striated muscles (so called 
voluntary muscles) may be grouped roughly under three headings, 
(a) hyperkinesis, (b) hypokinesis and akinesis, (c) hypertonia and hypo- 
tonia. The last group is not coordinate with the other two groups since 
muscle tonus is derived, to a considerable extent, from stimulation of an 
interoceptive and proprioceptive nature. The voluntary control of 
muscular movement is dependent to a large extent upon exteroceptive 
stimulation although both interoceptive and proprioceptive stimulation 
are of vast importance. 


Movements during maniacal excitements, tremors, spasms, convul- 
sions, athetosis, and chorea (St. Vitus dance), are all hyperkinetic 
movements. During maniacal excitement, patients frequently are dif- 
ficult to restrain. They exhibit over-activity of all kinds of muscular 
responses including speech. Their movements seem to be speeded up, 
and their strength appears to be very greatly increased. Almost every- 
one is familiar with the fact that it frequently requires the combined 
efforts of several strong men to restrain a maniac of this type. All 
maniacs, however, do not exhibit this unusual form of activity. Un- 
fortunately, the measurements that have been made to determine the 
true status of the speed and strength of muscular reactions of these 
patients are unsatisfactory. That they exhibit either speed or strength 
above their normal possibilities must be questioned. The probable 
explanation for their apparent increase lies in increased motivation and 
the rapid shift of direction of movement. Their coordinations are of an 
unexpected nature, hence they are difficult to anticipate. Some ex- 
periments which deal indirectly with speed of movement of abnormal 
subjects have been performed by various investigators. Franz (157)? 
Wells and Kelley (158), Lundholm (159), Saunders and Isaacs (160) 

1 For a more detailed discussion of some of the motor disorders, the student is referred 
to: Motor Disorders in Nervous Diseases, by Ernest Heitz and Tracy J. Putnam, Kings 
Crown Press, New York, 1946. 


have measured reaction time. Their conclusions are that in the psy- 
choses the average reaction time is lengthened and the variability is 
greater or different in type. Lundholm holds that the variability of the 
reaction time in the psychotic subjects must be considered primarily as a 
manifestation of an attentional disturbance. 

A tremor is a slight muscular rhythmical contraction. These may 
be coarse, fine or fibrilllary; continuous or intermittent; slow or fast. 
The first distinction depends upon whether the tremor is produced by 
contraction of separate muscle fibrils. If so, it is a fibrillary tremor. 
A tremor is arbitrarily called slow if the contraction rate is not more 
than 6 or 7 per second; fast, if the rate is 10 to 12 per second. Tremor 
rates are characteristic of the discharge rate of cells located in different 
parts of the nervous system. Tremor rates of 9 to 15 per second are 
typical of tremor originating in the cerebral cortex; 5 to 6 per second are 
typical of tremor originating in the corpus striatum; 3 to 4 per second 
are indicative of tremor arising in the motor cells of the red nucleus; 
and, 6 to 7 per second may be identified with cells of the anterior horn 
of the spinal cord. A continuous tremor is one similar to that seen in 
paralysis agitans (shaking palsy or Parkinson's disease). It is likely 
to be remittent and is diminished by voluntary effort. The intermittent 
type occurs only at intervals and may accompany any voluntary motion. 

Booth (161) believes that there is a psychological component in 
Parkinson's disease. The personality structure is developed from con- 
stitutional factors with emphasis on aggressiveness and a tendency to 
be identified with the dominant parent. This is combined with an 
inferior position regarding competition in childhood. The disease symp- 
toms of rigidity of behavior and compulsiveness of motor system furnish 
satisfaction on a symbolic level. A differential diagnostic technique for 
doubtful cases of Parkinson's disease has been suggested by Gordon 
(162). There appears to be hypersensitivity to a vibrating tuning fork 
when placed on metacarpal bones. This hypersensitivity is on the 
affected side. In hysteria patients, bilateral paralysis agitans, tremors 
of senility, the vibration is perceived with equal intensity of both sides. 

Tremor may be produced in many ways. Normally, it accompanies or 
is produced by cold, sorrow, or fear. If these cause tremor sufficiently 
often, it may become habitual. Even a single particularly vivid emo- 
tional experience may also be sufficient to predispose toward a tremor 
response. When the tremor becomes habitual, or fixed, it is called 
abnormal. In epilepsy and hysteria, both spasms and tremors are en- 
countered. In the latter they are of psychological origin and in the 


former they may be. The explanation and therapy of these tremors 
depends upon their genesis. The following cases cited by Sidis (163) 
furnish an adequate picture of the phenomena and throw light on their 
causes and treatment. The first case is quoted; the second summarized. 2 

M. L., nineteen years of age. Family history is negative, his parents died when the 
patient was young, and he was left without kith and kin, so that no data could possibly be 

Physical examination is negative. Field of vision is normal. There are no sensory 
disturbances. The process of perception is normal, and so also is recognition. Memory 
for past and present events is good. His power of reasoning is quite limited, and the whole 
of his mental life is undeveloped, embryonic. His sleep is sound; he dreams little, wets 
his bed since childhood. Digestion is excellent; he can digest anything in the way of 
eatables. He is of an easy-going, gay disposition, a New York "street Arab." 

The patient complains of "shaking spells." The attack sets in with tremor of all the 
extremities, and then spreads to the whole body. The tremor becomes general, and the 
patient is seized by a convulsion of shivering, tremblings, and chattering of teeth. Some- 
times he falls down, shivering, trembling and shaking all over. The seizure seems to be 
epileptiform, only it lasts sometimes for more than three hours. The attack may come 
any time during the day, but it is more frequent at night. 

During the attack the patient does not lose consciousness, he knows everything that is 
taking place around him, he can feel everything pretty well; his teeth violently chatter, 
he trembles and shivers all over, and is helpless to do anything. There is also a feeling 
of chilliness, as if he is possessed by an attack of "ague." The seizure does not start 
with any numbness of the extremities, nor is there any anesthesia or paresthesia during 
the whole course of the attack. With the exception of the shivers and chills, the patient 
claims he feels "all right." 

Patient was put into a deep hypnoidal condition. There was some catalepsy of a tran- 
sient character, but no suggestibility of the hypnotic type. In this hypnoidal -state it 
came to light that the patient "many years ago" was forced to sleep in a dark, damp 
cellar where it was bitter cold. The few nights passed in that cold cellar he had to leave 
his bed, and shaking, trembling, shivering and chattering with cold he had to go to urinate, 
fearing to wet his bed, in expectation of a severe punishment. 

The patient, while in that intermediary, subwaking hypnoidal state, was told to think 
of that dark, damp cold cellar. Suddenly the attack set in, the patient began to shake, 
shiver and tremble all over, his teeth chattering, as if he was suffering from great cold. 
The attack was thus reproduced in the hypnoidal state. "This is the way I have them," 
he said. 

During this attack no numbness, no sensory disturbances, were present. The patient 
was quieted, and after a little while, the attack of shivering and cold disappeared. The 
room in which the patient was put into the hypnoidal state was dark, and accidentally 
the remark was made that the room was too dark to see anything; immediately the attack 
reappeared in all its violence. 

It was found later that it was sufficient to mention the words "dark, damp, cold" to 
bring on an attack even in the fully waking state. We could thus reproduce the attacks 

2 Reprinted by permission from B. Sidis, Symptomatology, Psychognosis and Diag- 
nosis of Psychopathic Diseases. R. G. Badger Co. 


at will, those magic words had the power to release the pent-up, subconscious forces, and 
throw the patient into convulsions of shakings and shivering, with feeling of cold and 
chattering of the teeth. 

Thus the apparent epileptiform seizures, the insistent psychomotor states of seemingly 
unaccountable origin, were traced to dissociated, subconscious systems, now lapsed and 
meaningless in the patient's present environment and life reactions. They are recurrent 
reversions, atavistic manifestations of lapsed, now meaningless groups of psychomotor 

Case 2. Male patient of Russian extraction whose age was 21, was referred to Sidis 
for epileptiform attacks and anesthesia of right half of the body. This involved all the 
senses of the right side including olfaction, gustation, vision and audition. The reflexes 
were normal. No history of venereal infection or nervous disorder could be obtained. 
The attacks consisted of a series of spasms, rhythmic in character, which lasted for about 
two minutes. After a thirty second interval the spasms set in again. They would 
continue for five or six days while the patient was awake and ceased only during the 
short time which he slept. The attacks began while the patient was fully awake and 
during the attack the mind was perfectly clear. All sensations of the right side of body 
were lost; the patient was actually not aware of spasms unless he saw the affected limbs. 
The attacks occurred only once a year usually about January or February. The history 
of the case Sidis gives as follows: "The first attack came on after peculiar circumstances, 
when the patient was sixteen years of age and living in Russia. After returning from 
a ball one night, he was sent back to look for a ring which the lady, whom he escorted, 
had lost on the way. It was a lonely road which led by a cemetery. When near the 
cemetery he was suddenly overcome by a great fright, thinking that somebody was 
running after him. He fell, struck his right side, and lost consciousness." 

"By the time he was brought home he had regained consciousness, but there existed a 
spasmodic shaking of the right side, involving the arm, leg and head. The spasm per- 
sisted for one week. During this time he could not voluntarily move his right arm or leg, 
and the right half of his body felt numb. There was also apparently a loss of muscular 
sense, for he stated that he was unaware of the shaking of his arm or leg, unless he looked 
and saw the movements. In other words, there was right hemiplegia, anesthesia, 
and spasms." 

During hypnosis, the patient was made to recall the scenes involved and by this method 
the dissociated facts relative to his attacks were integrated. 

The tremor accompanying alcoholic delirium is of a similar nature. 
Other patients exhibit tremors following diseases in which the organism 
is left in a very weakened state. Typhoid, pneumonia, and influenza 
are typical diseases which result in muscular weakness. Both mental 
and physical fatigue if sufficiently severe will cause a manifestation of 
this type of muscular action. Electrical stimulation of the motor 
nerves or of the muscles may also produce it. 

One explanation of tremor of organic orgin is the inability of the 
muscle fibers to respond to their normal innervation because of depletion 
of the available glycogen by fatigue. The muscles then respond only 


partially. Another view based on glycogen depletion is that there is a 
differential in the rate of fiber depletion, consequently the fibers contract 
in a nonuniform and uncoordinated fashion. 

Other explanations are based on irregular or continuous innervation 
because of a central paralysis of some kind due to toxins, or to the en- 
feeblement of innervation so that the muscle fibers are not adequately 
set in action. 

In contrast with the tremor movements which have just been dis- 
cussed, attention must be given to the energetic contractions of relatively 
larger muscle groups. When a muscle or group of muscles is contin- 
ually contracted it is called a tonic spasm; when these contractions occur 
repeatedly they are designated as clonic spasms. Long, painful con- 
tractions are called cramps. The student must recognize the fact that 
spasms may be either functional or organic in origin. If they are func- 
tional in nature, they are referred to as tics or various types of neuroses 
such as habit neuroses or occupational neuroses. The true organic 
spasm is due to physical causes and is not directly affected by voluntary 
or emotional control. A spasm known as a toxic spasm may be 
induced by an over dose of alkaloids, or by blood poisoning (caused by 
clostridium tetani). Another typical spasm is the bronchial spasm of 
asthma. Asthma may be of a reflex nature in conjunction with hyper- 
irritability of the sympathetic system. Asthma has also been attributed 
to an allergic condition to many kinds of material, such as proteins, 
dust, feathers, and hair. If this assumption is correct, then the removal 
of the allergic substance will tend to prevent the occurrence of the spasm. 
Epinephrin administered in appropriate amounts will tend to break up 
some attacks and inhibit others. Followers of the psychoanalytic 
school have placed great emphasis on emotional factors in asthmatic 
seizures. Such writers as French (164), Freyhan (165), and Goiten (166) 
present information on this point of view. 

French maintains that the asthma attack results from a conflict 
situation and is tied up with defenses developed to overcome or master 
the situation. There are three types of defense found in practically 
all cases: 

(1) An urge to seek reconciliation with the mother by means of con- 
fession for unconscious wishes directed toward the mother. 

(2) Mastery of a traumatic experience which has been passively 
experienced by active repetition of the experience. For example, sexual 
temptation may precipitate an attack, whereas sexual gratification of 
the forbidden impulse rarely does. 


(3) Withdrawal from the temptation situation and a substitution of 
other erotic outlets. There have been cited asthmatic cases whose 
skin tests showed sensitivity to ragweed, cat's hair, and horse dander. 
When the psychoanalytic therapy was completed, the allergic reactions 
themselves disappeared. 

It is somewhat difficult to reconcile the psychoanalytic approach with 
the strict organic approach. If, however, we make one basic assump- 
tion, the gap can be considerably narrowed. 

Let us assume that prolonged tension or worry is involved in most 
cases. This may result in an eventual hypofunction of the adrenal gland; 
hence a crisis situation is not broken up by a loading of the system with 
epinephrin. Since some attacks may be dissipated by injections of 
epinephrin and since records exist of attacks being broken up under 
extreme conditions of fear, we may assume that any procedure that 
would result in appropriate levels of epinephrin in the system would 
overcome the condition. The analytic procedure then may resolve 
the tension factor which may have caused dysfunction of the adrenals; 
hence the essential mechanism is similar. 

Electrical stimulation of the motor cortex, motor neurones or the 
muscle plates will bring about a muscular spasm. Destruction of brain 
areas or intracranial pressure are adequate causes for this action. The 
tic doloreux which is due to neuralgia of the trigeminal nerve is not 
strictly a tic in the sense in which we have defined tic and is treated 
frequently by injection of alcohol into the nerve. 

It is necessary to discuss further the relation between tics and oc- 
cupational neuroses. A tic may be defined as a coordinated purposive 
act, provoked in the beginning by some external cause or by an idea. 
By process of modification in learning or repetition it becomes habitual 
and involuntary. The occupational neurosis is the inability to repeat 
what was originally an habitual voluntary act. Typical examples of 
occupational neuroses are writer's cramps, telegrapher's cramps, taxi 
driver's neuroses and sewing machine operator's neuroses. In all these 
cases the act cannot be executed as it was originally, although the 
muscules are not fatigued. The evolutionary act does not occur be- 
cause of a central blocking. Tics also called compulsion neuroses, on the 
other hand, are accompanied by a consciousness of the act. They are pre- 
ceded by a strong desire to carry out the act and the performance of it 
leads to a feeling of relief. Furthermore, these automatisms disappear 
during sleep and may be mitigated by distraction. The characteristic 
of the tic is such that it may have little or no resemblance to the causal 


factors. Tics may involve practically any muscle group and result in 
any variety of bizarre actions. Such actions as fluttering of the eyelids, 
sniffling, wrinkling of the forehead, distortion of the mouth, nodding of 
the head, shrugging of the shoulders, hand washing and so forth may 
be called tics. The two following examples summarized from Meige 
and Fiendel (167) show the etiology of certain actions. 

To escape the pain of a dental abscess on the right side, of only 4 
or 5 days duration, the patient had acquired the habit of turning the 
head to the right and maintaining it so, for as long as possible at a 
time. Very shortly after the healing of the abscess, the head com- 
menced to move involuntarily toward the same shoulder. 

A school girl was dissatisfied with the place allotted to her in the 
school room, and pretended that she felt a draught on her neck coming 
from a window on her left. The initial movement was an elevation of 
the shoulder as if to bring her clothes a little more closely around her 
neck, then she commenced to depress her head and indicate her dis- 
pleasure by facial grimaces and these eventually passed beyond her 

The writers have worked with a patient about 40 years old in 
which there was a marked desire to wash the hands 4 or 5 times before 
stopping. This patient characterized his actions as foolish but said 
that he did not feel right until the act was accomplished. He could 
throw no light on the beginning of the habit nor could he offer any 
explanation for it. It actually began at about the age of 18 and the 
system of responses from which it sprang was centered in an unfortunate 
heterosexual experience. 

Levy (168) believes that certain kinds of tics or stereotyped movements 
in children arise because of restraint imposed on activity. He bases his 
idea upon observations of animals, such as chickens, bears, and horses, 
confined to small quarters. These animals frequently develop head 
movements which tend to disappear when greater activity is allowed. 
Head rolling and similar rhythmical head movements in children may be 
related to restraints imposed by the crib or clothing. Actual reaction to 
restraint of finger sucking is varied, but the most violent reaction is 
elicited by the elbow splint. 

A study by Mahler and Luke (169) with a limited number of cases 
seems to indicate that the prognosis for tics is not too favorable. They 
followed up 10 male children from ij to u years of age after the original 
diagnosis of tic was made. Of the 7 who had reached military age, 3 
were classified 4F; one was in a mental hospital; and 3 were doing well. 


The other 3 patients were of school age at the time of follow-up and were 
found to have slight residual tics. In the 6 cases in whom the present 
adjustment was favorable, the investigators felt that the adjustment was 
due to rinding an adequate motor release rather than due to either depth 
or length of psychotherapy. 

Convulsions, myoclonic movements, athetotic and choreic movements 
are classified as hyperkinetic. These are primarily organic in origin 
with the exceptions of myoclonus and hysterical convulsions. Organic 
convulsions may be produced by toxins such as those in uremia, numer- 
ous drugs, lead, strychnine, or by absinthe. They may be provoked by 
mechanical or electrical stimulation of the motor cortex. An epileptic 
convulsion is usually accompanied by loss of consciousness; this differs 
from the convulsions of hysteria patients in which there is only a pseudo- 
loss. The second case of Sidis which was cited earlier in this chapter 
showed characteristic behavior with respect to consciousness of his 
acts. In convulsions, the muscular system is involved to a greater 
extent than it is in tremors and spasms. This is particularly true of the 
large muscles of the arms and extremities. Myoclonic movements are 
the contractions of isolated muscles without the involvement of the 
conscious processes. These may be observed during sleep and occur 
in the normal person in the form of occasional muscle twitches. Those 
occurring during sleep are usually explained by partial integration at a 
level below the conscious level. They may also indicate a calcium 
deficiency. Myoclonic activity is exhibited in the various choreas. 
These choreas are referred to by specific names depending upon the 
localization and extent of the muscular contraction and upon the pro- 
gression and non-progression of the disease. St. Vitus dance (Syden- 
ham's chorea) and Huntington's chorea are the most frequently men- 
tioned forms. Choreas are observed most often in children and they 
prevail in girls more than in boys; the ratio is approximately 2 to i. 
prevail in girls more than in boys; the ratio is approximately two to one. 
Choreic symptoms may result from brain lesions and brain tumors as 
well as from other organic causes. Certain choreiform movements may 
be functional. Their origin and treatment is very similar to that of 
spasms, tics and cramps. 

Athetosis is a condition characterized by tentacle-like movements of 
the arms and legs. There is a continual slow change of position of the 
fingers and toes. It can be observed among low grade morons and 
idiots. Its occurrence is attributed to lack of development of certain 
parts of the brain, and it appears in normal individuals following certain 


brain lesions. A series of pictures illustrating athetoid movements 
following a brain lesion are shown in Plate I. Keiller (170) reports a 
case in which Horsley removed the anterior central convolution. This 
produced relief for the patient. Athetoid and choreic movements are 
probably due to lesions in the neostriatum or thalamus. Hoefer and 
Putnam (171) have studied the action potentials in Sydenham's chorea 
and athetosis. They find that the motor discharges are asynchronous 
and polyrhythmic. Antagonists are in almost constant simultaneous 
innervation during both voluntary and involuntary movements, whereas 
during periods of rest no tonic innervation is noticed in the muscle. 

An interesting experiment by Palmer and Zerbe (172) would seem to 
indicate that athetotic tremors may be influenced by conditioning 
techniques. A young male with a typical athetoid tremor of right index 
finger was subjected to a series of loud auditory stimuli. Control of 
severity and rate of tremor was at least partially obtained. Cessation 
of the stimuli produced remission of tremor; when the series was com- 
pleted remission of the tremor lasted for 6 weeks. 

In pointing out the differences which exist between the various kinds 
of hyperkinetic movements, it is possible that the total picture of these 
disorders has been lost. Tremors, spasms, convulsions, tics, and 
choreas are only different aspects of muscle functioning and muscle 
groupings. There is somewhat of a graded series of the size of move- 
ment, the rate of movement and the number of muscles involved. All 
of these specific disturbances may be either functional or organic. 
Their treatment will depend upon the etiological factors. Practically 
any one of the disorders may be produced by the same organic cause or 
by the same psychological cause. A tremor, spasm, or convulsion may 
result from an over-dose of the same toxic substance or they may all 
occur in different hysterical patients as a result of the same psychological 



There are other disorders of the effectors which are hyperkinetic in 
type. These include certain disturbances of gait, writing, gesture and 
speech. These will be discussed under their respective headings. The 
aspects of general muscular control which have not been treated are 
akinesis, hypokinesis, hypotonia, atonia, and hypertonia. The first 
and second of these disorders are related to the topic of voluntary 
muscular (striated muscle) disturbances. Akinesis means the loss of 


ability to move or motor paralysis. Hypokinesis means a slowing 
down or enfeeblement of movement. The most common organic cause 
of these disorders is syphilis. Ravages of this infection in the neural 
system result in paresis and paralysis depending upon the spread of the 
infection. Poliomyelitis (infantile paralysis), thrombosis (blood clot 
in the brain), arteriosclerosis (hardening of arteries), lead poisoning 
which attacks the peripheral motor nerves, and any lesion of the motor 
cortex or motor pathways are causes of paralysis. The nature of the 
paralysis will depend almost entirely upon the position of the lesion. 
When the paralysis is restricted to a given muscle group or region, a 
prefix denoting the region is supplied to the term plegta. The terms 
monoplegia, hemiplegia, diplegia, paraplegia, and ophthalmoplegia 
refer to such localized loss of movement. Monoplegia is paralysis of a 
single limb; hemiplegia, paralysis of one side; diplegia, paralysis of 
both sides; paraplegia, paralysis of lower extremities; ophthalmoplegia, 
paralysis of the eye muscles. 

Failure to make voluntary muscular responses is found in many cases 
of hysteria, catatonic dementia praecox, and schizophrenia. The 
miracle cures of paralysis happen to those people who are suffering from 
functional paralysis. Individuals who throw away crutches at religious 
revivals, those who get up and run after being unable to move for a 
number of years, when some one screams fire, mad dog, or snake, suffer 
from functional rather than organic paralysis. The catatonic postures 
and fixed positions of the schizophrenics do not arise usually in the same 
way, psychologically. For the present, it is unnecessary to go further 
into detail concerning the general paralyses. 

There are certain disturbances of locomotion and movement which 
are definitely linked with paralysis. The festinating gait, paraplegic 
and hemiplegic gait belong in this category. These particular move- 
ments result from the inability to move members of the body in a normal 
way, because of lesions in various portions of the efferent system. The 
festinating gait is characterized by an increase in speed as the individual 
attempts to go from one point to another. There is usually a flexion 
forward of the upper portion of the body. The steps are very short. 
It appears as though the individual is making rapid short steps to keep 
from falling on his face. This gait frequently accompanies paralysis 
agitans. The hemiplegic gait is a result of paralysis of the leg from the 
hip. Since the leg cannot be bent at the knee, movement takes place 
by elevating the hip and swinging the leg in an arc. In the typical 
case of organic paralysis with hemiplegia, the lesion occurs in the motor 




In this series of photographs, which are taken at intervals from a motion picture film, are 
portrayed athetoid movements resulting from a lesion which occurred during birth. The 
youngster is reaching for a block on his right which is to be placed on the vacant white 
square before him. Notice the contorted movements as well as the overflow of activity to 
parts of the body not actually necessary for executing the task. The drooping of the eye- 
lid and the change in the musculature about the mouth are especially clear in frame 10. 

Reproduced through the courtesy of The Training School at Vineland, New Jersey. The original study 
from which these pictures were taken was made at the Vineland Laboratory under the direction of Dr. Edgar 
A. Doll in cooperation with Dr. Winthrop M. Phelps with the assistance of Miss Ruth T. Melcher and Miw 
S. Geraldine Long well. 


neuron. Partial stimulation from the vestibule and cerebellum is still 
extant. In the paraplegic gait, many of the same factors are involved. 
There is a loss of movement of both lower limbs and progression takes 
place almost entirely from the hip movements. The postural stimula- 
tion is intact. 

Movement and gait are also influenced by muscular weakness and 
defective afferent muscular sensation. These factors result in clumsy, 
incoordinated actions, which are designated generally as ataxias. The 
symptoms of ataxia which have their origin in defects of the kinesthetic 
sense are inability to walk a straight line and inability to find one's 
way around in a familiar dark room. Incoordination -will be exhibited 
when the eyes are closed, in such simple tasks as touching the index 
fingers of both hands; touching the nose or the ear. There is also 
marked inability to determine the position of the members of the body 
under the same circumstances. When the eyes are open, these coordi- 
nations and movements are executed with much greater precision than 
when they are closed. When the ataxia is brought about by cerebellar 
or vestibular tract lesions, it is designated as cerebellar or vestibular 
ataxia. The gait is that of the drunken man, with the legs spread wide 
apart. There may be a tendency toward stumbling and inability to 
maintain equilibrium. These ataxias differ from those originating from 
sensory lesions in that the ataxias are not increased by closing the eyes. 
The ataxis is more pronounced on the side of the lesion if it is not bi- 

Beers and Cheever (173) in a study of 6 generations of kinship found 
1 8 males and 2 females who manifested an ataxic gait. Syphilis was 
excluded as a cause, hence the probability that this form of gait may 
be transmitted genetically at least in some cases. 

The vestibular ataxias usually show recovery and compensation for 
the loss in coordination. The explanation of the modification of ataxic 
movements by closing the eyes is relatively simple. In the normal 
development of space perception and muscular coordination, the impulses 
from the visual sense are integrated with those from the kinesthetic 
sense. When the kinesthetic impulses are removed through some dis- 
order, only the visual sense furnishes clues to the motor areas involved 
in movement. With the visual impulses removed, the coordination 
becomes even less exact. Static ataxia manifests itself in the inability 
to coordinate while standing with the feet placed together and the 
eyes closed. Swaying and even falling may occur. This is Romberg's 
sign and may be expected in tabes dorsalis, hereditary cerebellar ataxia 
and other disorders of the central nervous system. 


Static ataxia and certain of the other ataxias are very closely allied 
with muscle tonus. This is normally supplied by incoming impulses 
from the skin, tendons, and joints. The afferent impulses from these 
sources keep the muscle in a partial state of contraction. In certain 
diseased conditions, the muscles may become flaccid, that is, they may 
lose tonus. In other forms of disease the muscles may become spastic, 
that is, the tonus is too great. In either case, coordination is interfered 
with. Spastic paralysis, (loss of voluntary motion with muscular 
rigidity) which is of organic origin, is always due to upper motor neuron 
lesion; flaccid paralysis (paralysis without muscular rigidity) occurs in 
lower motor neuron lesion, with transverse lesion of the spinal cord, 
and in some other types of lesion. Temporary spastic and flaccid 
conditions of the muscles may be found under strong emotional ex- 
citement. It is also well known that the striated muscles lose tonus 
during sleep since most of the afferent impulses are cut off. Ataxias 
may manifest themselves in some cases of functional disorders. Their 
origin and treatment is similar to that of functional paralysis, tics and 
many forms of sensory loss. 


Reflexes are usually considered invariable in their action. It was 
pointed out earlier that this statement is true only in a rather limited 
way. Many of them are affected by volition and many others become 
exaggerated or disappear with pathological conditions. Clinical 
neurology recognizes a long list of reflex actions which are useful for 
determining lesions in the brain and spinal cord. The list in table 12 
(pp. 106-108) may be helpful in acquainting the student with the reflexes. 

The list of reflexes is not complete. There are reflex factors in the 
control of respiration, the heart rate, peristalsis, the glands of internal 
secretion and various sex functions. The control of some of these 
reflexes is through the sympathetic nervous system. Certain of these 
may be considered as secondary reflexes resulting from emotional dis- 
turbances and disturbances of the vegetative functions. For our 
purposes, the tabulation given shows the reflexes most frequently dis- 
turbed by organic conditions occurring in psychopathic individuals. 
The failure to elicit most of these reflexes indicates in general at least 
a segmental lesion of the cord. In other central lesions, particularly 
of the motor cortex and thalamus, certain of these reflexes may be 
increased or exaggerated. Figure 21 shows schematically the neural 
pathways involved in a simple reflex. 

In the functional mental cases, these reflexes are not usually affected. 




g s| 


T3 ,1 

rt C 








co 'S 









h-l VQ 

* t __, 






**2 . 

= ! 

1 1 * 



tT ^ 


s 1 g-s 

C ^3 O vo 






"rt 2 
.g g 








ty of cord 
icic nerves 

*S ^ 
b S-jj 


1 "o 2 "S 

in some 







J3 co 









*-> co 03 



W J) 


i s 


c c 

rt T3 
.e> c 

' 5 1 










=3 T3 





g rt 




"rt C 






S S. 





'fi -S 


c w 




O co 



"rt **^ 








2 ^ 



M J^ 








rt *"* 













c o 

o c 







,, 'r" 

_S ^3 





t . 

1 f 







K c 3 

11 'I 











o j^ 




A H 




i i 

















3 . 




n J^ 




*" O 





















I 1 




u rt 



Contraction of 





Contraction of 

Clonic contrac 
Contraction of 

' s c 

.S "" 


c c 

rt rt 
J3 _C 

U U 


Change in size 
for accomm 

Dilation of puf 

Flexion or exte 

one on oppos 
Eye lid closure 






















1 = 




1 bB 





























I0 7 

Integrity of cord between 1st and 
2nd lumbar nerves 

Integrity of cord from 4th to yth 
thoracic nerves 






1? O 


"S T? 

to 2 







S ^ 
w -2 


May be produced by myelitis 
Cord integrity in the region of the 
4th and 5th lumbar nerves 

Normal response of adults. Seg- 
mental control by 5th lumbar, 
1st and 2nd sacral 

Normal response in infants to 6 
months. In adults this response 
indicates a pyramidal lesion or 

a lesion of the pyramidal fibres. 
May result from a toxic condi- 

Pyramidal tract lesion 

Pyramidal tract lesion 


^0 ^ < w' ^ 

S.I 111 
f a 1 

sence does not necessarily indi- 
cate a lesion 










j2 C 







Jj u 




C ^ 






S H 


"co C 





"3 < 


13 S 






& 1 



.2 ^ 



imulation of 
6th interco 


rimulation o 
anterior port 

:roking the sk 





iroklng soles ( 



1 ll 
















8 8 S 




4-* O 


3 5 


OT 2 









g 1 



! * 






^ .^ 


V l-i 

. o 





J3 <*-. 

+-> o 


M S 



3 C a 

flexion oi 
:; extensi 


















o w 

"^ > -^ CO 


v ' 


S 2 

H, c 



S gl! 

~ I 2 
c g 




s s 







2 "S PH "So 














































1 08 



rdinarily. Is found 

of lateral columns 


1 | 



O _r> 

S * 

i "2 

^ 111 111 || || 

=3 jj S- "a -S x 1 g s J-1 

c S - 5 'C c - jp-c " c *** 

f|||l|j] 1^3 s 





.2 ^c 

*CO 4^ 

_w O 



















H3 8 

i-g'-SoO^^-^ <*H=!2o 

|_ ^^ 



*H v *- 





2 .S2gz3T3o o>^%2u 

rt Q 



o o 




^l 1 

1-s i*a J * .& p .&. * s % 

"3- 8 ! ~ "^ & ^'30 8 

1J ;>% co 

4-> CD 










c c: 













rt ^ C 




^ .2 





g rt 





5 c 

j ? ~3 




S ."3 1 








-e ii 













'w ^ 

g ^ .2^ u 











u ^ 


l}| I 






Blow on bon 

Irritation of 










CO 'C 


^ 'O 






<D ^^ 














ic move 

1 S 

1 -1 is 












f s^ g 

U co 





u 13 
rt ^ 




1 1 




>L ~ 




* VH 



J ^ 











FIG. 21. Patellar reflex, showing the simple route and two possible modifications. The 
arrows indicate the direction of the impulse, the sensory tracts are shown as solid lines, 
and the motor tracts as broken lines. S\ and S 2 , sensory tracts; MI and M 2 , motor tracts; 
d, C 2 and C 3 , connecting fibers. The simple reflex is shown as route A. The central modi- 
fication as route A to cord, B to cerebrum and back, and A to muscle. The visual modi- 
fication is shown as route C to the visual cortex and motor cortex, route B to the cord and 
route A to the muscle. 


In fact, one method frequently employed for detecting functional losses 
is to determine if the reflexes are still present. 


Speech is subject to a very great variety of disorders. They range 
from verbomania to mutism and many perversions are exhibited. These 
disorders are intelligible only if a complete picture of the development 
of normal speech and the speech mechanism is presented. Normal 
speech is dependent upon the correct functioning of several of the special 
senses. Not only the receptors for these senses must be intact but also 
their afferent pathways with their specialized areas in the sensory cortex 
must function adequately. The auditory sense, the visual sense and 
the kinesthetic sense function directly in the development of speech 
and communication. On the motor side, the muscles of the larynx, 
the tongue, pharynx and those involved in respiration must be organ- 
ically and functionally intact. These muscles are controlled efferently 
by the motor cortex and the motor tracts in the brain stem. There 
are certain disturbances in speech which must be attributed to the 
central or association mechanism. Thus far, this mechanism has not 
been discussed. Association and its mechanism will be given considera- 
tion in this chapter only in so far as it affects speech. 

Speech is an incorrect term for the whole topic which will be treated. 
Language or communication disorders would be more appropriate. 
Since individuals communicate with each other to a large extent by 
vocal means, speech is loosely used to include written communication, 
sign communication and gesture. It is obvious that these latter ways 
of communicating are not controlled in an identical way as speech, but 
their development and their function are primarily the same. 


The development of speech commences at birth and possibly in utero. 
Among the first speech reactions are those of crying. These early 
crying reactions are not differentiated. That is, there is not a particular 
cry for pain, hunger, wanting attention, and so on. The cry serves the 
purpose of bringing relief to any undesirable stimulus and may even 
be for exercise of the vocal mechanism. As the youngster grows older, 
there is an increase in both the quantity and quality of stimuli to which 
it is subjected. The speech mechanism ordinarily develops part pastu 
with these stimuli. There is a gradual differentiation in the cry re- 
sponse. Other vocal sounds such as gurgling and indistinct speech 


sounds gradually are made. These indistinct sounds become progres- 
sively more distinct and from about fourteen months to two years 
speech comparable to that of the adult has begun. Since speech nor- 
mally develops gradually, disorders of acquirement may result. It 
must be remembered that vocabulary, pronunciation, and enunciation 
are constantly being modified throughout life by the environment in 
which the individual finds himself. If we assume that speech is ever 
normally acquired or reaches its full development, then we may expect 
certain disorders to arise in acquired speech under the influence of 
environmental and pathological changes. 

One of the earliest disorders of speech that can arise is a delay in 
beginning to talk. The failure to begin talking can be attributed to 
various causes. Faulty training and motivation can be suspected in 
most cases, although microcephaly and sensory disturbances, partic- 
ularly congenital deafness, may be responsible. In the case of the 
feebleminded, it has been found that an unusually large number show 
speech defects. Some imbeciles acquire speech at a very late age; 
others do not acquire it at all. Idiots, who have a lower order of men- 
tality, seldom develop speech. Town (174) has shown that from 50 
to 85 per cent of imbeciles manifest speech defects, depending upon 
the extent of the enfeeblement. Other studies by Wallin (175) have 
shown a high percentage of retardation in school by pupils having speech 
defects and a higher percentage of speech defects among colored children 
than among white children. While these studies do not give informa- 
tion on the delay in beginning to speak, they do show that speech dis- 
orders are more frequent among the mentally defective. It has been 
argued by some that defective speech is responsible for enfeeblement. 
It is true that poverty in speech and defectiveness in speech are indica- 
tive of amentia and may be partially responsible for lack of mental 
development. In many low grade feebleminded that portion of the 
brain that lacks full development is the cerebral cortex. This lack of 
structural development is influential in causing a retardation of all the 
so-called mental functions in contrast with the motor functions. Mor- 
phological brain conditions may be used as the basis for explaining the 
failure to begin talking at the correct age. Other morphological factors 
may be the basis for lack of speech development. Congenital deafness, 
abnormalities in size of tongue, cleft palate, abnormalities of uvula, 
arch and palate maldevelopment, or various conditions of nasal pas- 
sages, such as adenoids and changes in turbinate bones, are potential 
causes. With the exception of deafness, the above conditions, are more 


likely to produce disturbances of articulation and phonation rather than 
a delay in beginning to talk. 

Once speech has begun, the vocabulary acquired will depend upon the 
"intelligence" of the individual as well as his environment. Many 
intelligence tests include as a part of the battery a section dealing with 
the use and acquisition of language. One presupposes that these lan- 
guage sections are made up in such a way that they will include the 
vocabulary ordinarily acquired by the particular age level to be tested, 
under specific environmental influences. In this connection, some of 
the environmental influences on vocabulary acquisition are interesting. 
Brogues employed by national or stock groups are environmental in 
origin. Typical of these is the so-called Irish brogue. In contrast 
with the brogue, which is dependent to a large extent upon language 
development of groups, are the qualitative changes in pronunciation. 
The speech of the New Englanders or Bostonians, the speech of the 
so-called East Siders in New York, and the drawl of the Southerners 
are typical of qualitative changes. There are provincialisms which 
center in specific groups of words such as bag, toot, sack, spider, fry 
pan, stew pan, and so on. Trade and profession certainly influence the 
vocabulary which is acquired. Compare for example, the terms used 
by a carpenter with some employed by the biologist or chemist. In the 
vocabulary of the carpenter belong words such as mortice, tenon, stud, 
splice, and plumb; in the vocabulary of the last two will be listed brachy- 
cephalic, parthenogenesis, mitosis, diethylbenzine and esterification. 
The acquisition of these words by individuals who have occasion to 
employ them is to be expected. Excessive use of curses and oaths may 
depend to a large extent upon environmental influences. At least the 
acquisition of such words and phrases will depend upon whether the 
individual hears them. In the same category with provincialisms and 
expletives should be included excessive use of slang. The habits of 
speech which involve the use of slang are undesirable, although there is 
a tendency for slang expressions to be admitted into general use. Slang 
undergoes rapid changes, and most people are familiar with the jargon 
of adolescents and perhaps with the terms employed by the so-called 
gangsters. These slang expressions have a definite meaning that cannot 
be conveyed by ordinary words unless one is willing to engage in cir- 
cumlocutions, and hence are very apt for conveying meaning to the 
initiated. Their acquisition depends upon environmental factors to a 
large extent. A few examples of the changes through which slang goes 
will illustrate the folly of attempting to use it without keeping up to 


date. Certainly no form of speech is more ridiculed than the use of 
outmoded slang. Its use does not make for clear, concise thinking 
since it is constantly undergoing changes and since it is not understood 
by the majority of people. The following expressions have been used 
to apply to a man who is a ''snappy dresser" and has the ability to en- 
tertain the feminine sex: "Macaroni, Jim Dandy, Gay Blade, Spark, 
Fox, Coxcomb, Heavy Swell, Masher, Dude, Cake Eater, Lounge 
Lizard, Cowboy, and Neck Artist." These expressions have been applied 
to those who have indulged in the offerings of Bacchus: "Got a Bun On, 
Skate On, Jag On, Three Sheets to the Wind, Half Seas Over, Potted, 
Stewed, Oiled, Tight, Canned, Sopped, Slopped Up, Soused, Pie-eyed, 
and Shot." Some of these expressions are derived from particular 
circumstances and have slightly different shades of meaning. Their 
incorporation into one's vocabulary will depend upon hearing them or 
reading the type of literature in which they are embodied. 

The use of brogues, provincialisms, "swear words" and slang has 
its place. It is only when they are employed excessively or employed 
out of place that they must be viewed askance. Affectation of provin- 
cial speech, the use of slang by elderly people, and swearing under un- 
warranted circumstances are not indications of speech disorders per se y 
but are symptoms, in all probability, of some form of mental aberration. 

Montagn (176) holds that swearing may not belong in the same cate- 
gory with slang and provincialisms. He thinks that swearing results 
from frustration and serves to release tension caused by aggressive 
feelings. The differences between the two sexes with respect to the 
usage of this means of relieving tension is explained on social grounds. 
Women tend to resort to infantile weeping instead. 

The most prevalent and wide spread disorder of speech which arises 
frequently during the period of acquirement is stuttering or clonic 
spasms of the muscles of speech. The tonic spasms of the speech 
mechanism are called stammering. Fletcher (177) in his book on The 
Problem of Stuttering discusses the various speech aberrations that have 
been called stammering and stuttering. He also gives an account of 
the history of the present terminology along with the proposals of 
various writers for changes in terminology. The terms originated 
according to Fletcher from the use of the two German words "Stam- 
meln" and "Stottern." Schulthess employed these words about 1830. 
They came into general use through Meumann, and later differentiation 
was made by Scripture, who applied the term "lisping" to certain types 
of speech defects which are usually classified as stammering or stuttering. 


For purposes of discussion, the older and lay differentiation will be 
followed. Stammering is characterized by the inability to produce any 
sounds, although there is a definite voluntary effort to do so. This 
volitional effort may be accompanied by movement of the muscles of 
the jaw and tongue. Stuttering is characterized by the irregular repeti- 
tion of initial syllables of words or an impulsive breaking forth of the 

Hahn (178) has catalogued the speech sounds that give stammerers 
the greatest difficulty. On the whole, consonants are more troublesome 
than vowels and, among the consonants, g, d, 1, th, and ch are high on 
the list. Longer words were found by Brown and Moren (179) to be 
more difficult than shorter ones. The above arbitrary distinction is useful 
for descriptive purposes, but its usefulness clinically is practically nil. 
Both stammering and stuttering have to be treated in much the same 
way clinically. Bluemel (180), as well as other writers, has pointed out 
that these terms have been used to mean just the reverse. Other 
definitions and other terminology will lead to confusion of the reader 
and hence will not be presented. It was mentioned above that these 
disorders are quite prevalent. No distinction will be made between 
the two in discussing their frequency. Fletcher has estimated on a 
basis of Wallin's survey of the public schools of St. Louis that there 
are approximately 1,210,000 people in this country who have or have 
had this speech difficulty. This means about one per cent of the 
total population. An estimate made on a basis of figures given in 
the publication of the White House Conference on Child Health and 
Protection is slightly higher. The number of stutterers would be closer 
to 2 per cent. 

There are many factors which seem to have some bearing on stutter- 
ing. These may be considered independently of the actual theories 
which have been advanced for explaining these speech anomalies. 
Heredity, sex, age, intelligence, handedness, occular dominance, and 
racial factors have been scrutinized to determine their rolein stammering. 
Studies of the symptomatology of stuttering include breathing, reflex 
action time, cortical destruction in relation to handedness, traumatic in- 
juries of the brain, voluntary and involuntary muscular activity. These 
have added information which has been useful in formulating additional 
theories and opening up new lines of research. 

Before undertaking a discussion of the theories for explaining these 
speech defects, it is expedient to go more into detail concerning each 
of the above related phenomena. 


Studies on the hereditary aspects of stuttering are fairly numerous; 
two studies will illustrate, however, the general results. Meyer (181) 
found that stutterers were 10 times as frequent in families with histories 
of stuttering as in families without such histories. He could not discern 
an apparent Mendelian pattern for its inheritance. Nelson (182) studied 
69 pairs of apparent monozygotic twins and 131 pairs' of apparent 
dizygotic twins. Thirteen and seven tenths per cent of 138 monozygotes 
stuttered, whereas 6.4 per cent of 262 dizygotes stuttered. In addition, 
both members of the monozygotic pairs stuttered, while usually only one 
member of the dizygotic pair stuttered. These studies lend some 
credence to inheritance as a possible factor in the disorder, but the 
studies are not conclusive because of environmental factors that enter 
into the picture. The incidence of stuttering in the two sexes has given 
rise to various theories for explaining speech difficulty. The ratios 
usually stated vary from 2 to I up to 10 to i. This discrepancy among 
various investigators is due partly to differences in age groups examined 
and partly to their inclusion of various speech defects which are some- 
times not classified under stuttering. One theory on the point of sex 
differences is that advanced by Dunlap (183). His theory centers 
in the conflict of the acquired vocabulary which is taboo in the usual home 
life and other social situations of the boy. Dunlap states that boys 
acquire a vocabulary of obscene and profane words when they associate 
with other boys at an early age. Girls do not ordinarily acquire this 
vocabulary. Since the vocabulary is taboo at home and in school, the 
boy has to be constantly on guard lest these words creep into his speech. 
Some boys do not have difficulty in keeping their linguistic patterns 
separate, due to rugged innate constitutions. Others are not so fortunate 
in having a constitution that will withstand the constant strain necessary 
to maintain separately these two speech systems. The boy who is 
carefully brought up will likely hesitate; this hesitation will occur 
especially in connection with words that sound similar to, or in which 
the initial syllables are similar to obscene or tabooed words. This 
hesitancy spreads to all kinds of words. Schnell (184) gives this theory 
a slightly different interpretation. He contends that males are sup- 
posed to develop aggressiveness and independence while females pre- 
sumably are not expected to develop these traits. Aggressiveness and 
independence are the factors which are penalized in our cultural system 
hence stuttering is more frequent in the male. 

Differences in type of breathing and earlier development of the motor 
centers of the left cerebral hemispheres in females have both been offered 


as the causal factors of the sex ratio obtained. It has been held in 
this connection that women have predominantly a thoracic type of 
breathing in contrast with the abdominal type of breathing of men. 
This change in breathing was supposedly induced by corsets and girdles. 
Since thoracic breathing is theoretically most favorable for good speech 
habits, women manifested fewer disturbances. Fletcher criticizes 
the validity of the theory on a basis of the fact that the majority of 




FIG. 22. Distribution of degree of retardation for 599 school children who stutter. 
The abscissae represent successive years of retardation. The ordinates indicate fre- 
quency of cases for each year in terms of percentage. (Constructed after Wallin's data.) 

stutterers commence before the age when these influential conditions 
become operative. He made an additional check of the Japanese, 
among whom the dress of the two sexes was very nearly alike. In a 
report from the Bureau of Education of Japan, 135,852 boys and 20,637 
girls were affected with this disorder. These findings indicate that dress, 
in so far as it modifies breathing and in turn influences stuttering, is 
insignificant. In connection with the theory of Dunlap which has 
already been outlined, age may be expected to play an important role. 
Since the majority of stutterers begin the habit before entering school 
or in the first few years at school,it is not unreasonable to suppose that 
in this period of time, the child comes most directly in conflict with 


parental and outside authority. It is also the period when the youngster 
must begin to express his views or thoughts verbally before a critical 
audience. This latter idea has been developed by Fletcher in his theory 
of stammering. These conflicts with authority and possible fear of 
criticism of their verbal ideas, apparently lead to speech disorders. 
The rate of incidence is higher at these ages than in later years, due in all 






















FIG. 23. Cumulative frequency curves representing distribution of intelligence quotients 
for 905 unselected children and for 73 stuttering children. The solid line indicates the 
cumulative frequency of intelligence Quotients for normal children; broken line indicates 
same for the 73 stutterers. The abscissae represent intelligence quotient scores; cumula- 
tive percentages are shown on the ordinates. Compiled from data in Travis' .S/wfA 
Pathology and Terman's The Measurement of Intelligence. 

probability to the fact that pressure is more pronounced at a time when 
formation of speech habits is taking place. It has been suggested 
earlier that intelligence is related to speech defects. The next problem 
is to determine just how closely intelligence is related to stuttering. 
In special classes in the public school system an unusually large number 
of stutterers will be found. These classes in the majority are made up, 
of course, by those pupils who are mentally retarded. Superficial ex- 


amination of the preceding distribution curves (figs. 22 and 23) seems to 
deny and affirm the relation at the same time. Figure 22 is a represen- 
tation of data secured by Wallin in St. Louis. Figure 23 shows the 
actual distribution of I.Q.'s for 73 stuttering children superimposed on 
the distribution of I.Q.'s for a large number of normal children. It 
must be remembered that language is an essential element in the 
majority of intelligence tests. Since stutterers are deficient in this 
respect, it might be expected that they would be very inferior when com- 
pared with normal children by these standards. In spite of the fact 
that a large number of stutterers are retarded, there are quite a few 
that are advanced or above the average mentally. Most people can 
point out cases of stutterers who have become successful business men 
or teachers. Galton (185) was among the first to show that men of genius 
were afflicted in this manner to a greater extent than is found in the 
average population. Jacobson (i 86) later founded a theory for genius 
based upon neural instability and pathological conditions. To say that 
intelligence is the chief factor in the development of stuttering must be 

Personality differences have been scrutinized in many ways, but in 
general the only major conclusions are that stammerers tend to have 
some of the traits usually found among neurotics. Richardson (187) 
employing the Rorschach and the Thematic Apperceptive Tests found a 
difference between normals and stutterers in the movement and color 
responses on the former test, but no significant differences on the latter. 
We have already mentioned the disagreement concerning inferiority 
and aggressiveness. 


The relation of handedness to stuttering has occupied such a prom- 
inent place in many discussions that one might be led to believe that 
the whole problem of speech was one of handedness. The information 
on the point cannot be ignored, but the weight assigned to handedness 
needs to be decreased by a wide margin. Before attempting an analysis 
of stutterers who are left handed or who have been changed from left 
handedness to right handedness, let us examine the explanations offered 
for the preferential use of the left hand. Most individuals exhibit a 
preference for the use of the right hand; the estimated number of people 
who at one period in their lives exhibited preference for the use of the 
left hand is 20 per cent. There is considerable disagreement on this 
point, since the various estimates range from 2 to 20 per cent. Carrothers' 


(188) recent survey of 225,000 pupils in the schools of Michigan, reveals 
that 8.2 per cent are left-handed. There are certain others who do not 
show a preference and are termed ambidextrous. It must be 
remembered that preferential handedness is a matter of degree. Those 
who prefer either the one hand or the other perform many tasks with the 
hand that is not preferred. 

Travis (189) has developed the theory that handedness is determined 
by the development of a dominant gradient of excitation in the right or 
left hemisphere. He assumes that in the right handed individual the 
left hemisphere dominance occurs and in left handedness the right 
hemisphere dominance occurs. There is a lack of dominance, according 
to his theory, in the ambidextrous individual. He has summarized 
various experiments to explain this dominance of the left hemisphere. 
It has been explained on a basis of a quantitative difference in blood 
supply and on fetal position. In regard to the first causal factor Travis 
summarizes the theory of Jordan. Jordan (190) maintains that in the 
fetus, the branches of the aorta are so arranged in the majority of people 
that the left hemisphere and right arm receive a greater quantity of 
blood than do the opposite hemisphere and opposite arm. This ac- 
counts for the more adequate development of these neurological and 
anatomical structures. Any disarrangement of this circulation may 
result in a reversal of development and consequently in left handedness. 
Peterson (191) questions the validity of Jordan's theory. He ligated 
either the right or left carotid artery in rats before vascularization of 
the cortex occurred. Eighteen rats were treated in this fashion. When 
tested later for handedness, of 9 animals with the left carotid ligated, 
4 were left handed, 3 right handed, and 2 somewhat ambidextrous. 
Of the 9 with the right carotid ligated, 2 were right handed, 6 left 
handed, and I ambidextrous. It may be concluded that dominance of 
one hemisphere of the brain of the rat is not due to unequal blood supplies 
coming from the carotid arteries. Travis also cites the work of Tsai 
and Maurer (192) to prove his hypothesis. These investigators report 
that a vitamin B deficiency produced a greater number of left handed 
rats than is normally found. The author cannot see in the case of these 
animals why the deficiency should not operate towards producing an 
effect on both the cerebral hemispheres. There is another piece of work 
by Peterson (193) which has a greater bearing on Travis's theory. 
Peterson employed 7 rats in his experiment and used as his criterion of 
handedness the number of times out of 50 trials a rat reached for food 
with either its right or left forefoot. Of 6 rats, 3 were right handed, 


2 were left handed, and one ambidextrous. Cortical areas were de- 
stroyed on the left side of the right handed animals and on the right side 
of the left handed animals. On the animal that was almost ambi- 
dextrous a portion of the cortex on the left side was destroyed. After 
recovery from the operation, 5 of the animals showed a definite transfer 
in the use of the hands. One did not. The ambidextrous animal 
changed from the slightly favored hand to the use of the nonfavored 
hand. Milisen (194) in attempting to ascertain whether handedness 
in rats is innate or determined environmentally reached the conclusion 
that it is caused by the interaction of the two factors. 

The role that fetal position plays in developing cerebral dominance 
is not so well established. Travis maintains that stimulation arising 
from the vestibular apparatus is essential for controlling the normal 
fetal position. In this contention he may or may not be correct. He 
summarizes the work of Seaman and Precechtel, in which they have 
attempted to show the relation between abnormal fetal positions and 
speech defects. He has not tied this up directly with handedness 
although the implication is that many motor disturbances, including 
handedness and speech, must be controlled by these abnormal positions. 
Just how these positions influence the development of cerebral domi- 
nance he does not make clear. It has been suggested in connection with 
fetal position that the left arm is less capable of moving in utero. This 
may result in a general neural organization favoring the left hemisphere, 
since the right hand and arm are capable of slight movements which 
give rise to afferent kinesthetic impulses. It may be inferred theoret- 
ically then, that the causation of left handedness is definitely linked with 
the causation of stuttering. Overstreet (195), however, has compared 
eyedness and handedness with birth attitudes as obtained from the 
obstetrician in 85 subjects. She found practically a zero correlation. 
Cortical control of speech for right handed persons is located normally 
in the left hemisphere; for left handed persons it is located in the right 
hemisphere. When a change in the use of hands is forced upon the 
individual, an incoordination of the function of the two hemispheres 
occurs. Travis (196) says: 3 

My point of view is that in most cases the act of stuttering is a neuromuscular derange- 
ment secondary to general reduction in cortical head control. The latter is conceived 
to be due to transient and mutually inhibitive activities of the right and left cerebral 

3 Reprinted by permission from L. E. Travis, Speech Pathology. D. Appleton- 
Century Co. 


hemispheres. In the stutterer, instead of nervous energy being mobilized by one center 
of greatest potential, it is mobilized by two centers of comparable potential. Because 
both of these centers when operating singly function in reaction patterns of opposite 
motor orientation and configuration, there is produced in the peripheral speech organ 
an undesirable competition in the resulting muscular movements. 

Proof of the influence of change of handedness on stuttering centers 
in those cases in which the speech aberration develops concomitantly 
with the change in handedness. Bryngelson (197), according to Travis, 
studied 200 cases of stuttering and found that 62 per cent of them had 
been required to shift from the use of the left to the use of the right hand. 
Clinical studies by other investigators of some cases indicate that a 
change in handedness produces stuttering and when the individual is 
allowed to relapse into the use of the preferred left hand the speech 
difficulty clears up. War veterans, whose arms have been amputated 
because of injury, are reported to have developed a speech difficulty 
when forced to acquire new motor habits with the remaining arm and 

There is one factor which Travis has ignored in his discussion, namely, 
the widespread belief that a change in handedness produces stuttering 
and stammering. It is possible that suggestion or belief in this idea 
is the predominant element in the situation. Since stuttering may be 
relieved by suggestion in many cases, auto-suggestion is not an im- 
probable cause. Several cases treated by the author have been able to 
talk in quite fluent fashion while under hypnosis. Before the suggestion 
treatment has been completed, the old speech habits immediately mani- 
fest themselves, when the patients are awakened. Morsh (198), as well 
as others, has successfully transferred writing from the left to the right 
hand without any deleterious results. Fletcher (199) has criticised the 
importance of change in handedness in influencing speech. Using the 
data obtained by Wallin in the St. Louis Schools, he concludes that the 
notion is erroneous. It was found that only 4.9 per cent of the pupils 
who show speech defects were left handed and if those who had been 
changed from one hand to the other (so-called dextrosinistrals) were 
added, the percentage would be 9.9. Among those changed, only 9.4 
per cent exhibited any speech defect. Fletcher states "The fact that 
90.6 per cent of the children who were thus forced to change to right 
handedness suffered no such effects seems out of agreement with the 
theory as a whole." Further on in his discussion he says, "A rule that 
goes wrong in 90 per cent of cases will ipso facto lead one to suspect that 
other causal agencies in the case may have been overlooked." Parsons 


(200) contends that not a single case of stuttering could be found in the 
public schools of Elizabeth, New Jersey, that could be attributed to a 
change in handedness. This state of affairs existed in spite of a 4 year 
effort to change all left handed pupils. The writer wishes to stress the 
fact that a change in handedness in itself may not cause stuttering, but 
the method employed in changing the manual habits is of paramount 

Preferential handedness has been attributed to preferential eyedness 
by Parsons. In contrast with this point of view, the student should 
remember that Travis assigns both handedness and eyedness to cerebral 
dominance. Eyedness can be determined very simply by Miles' 
A. B.C. Test. This is nothing more than a cone shaped cardboard, 
large enough at one end for taking in both eyes and tapering to about 
an inch and one half at the other end. Have the individual look at you 
through this cone and notice which eye is visible. The visible eye will 
be the preferred eye. Parsons found about 30 per cent of school children 
were left eyed, and of these 12 per cent were left handed. This dis- 
crepancy is explained by the fact that the motor habits of the right hand 
must be developed by those whose natural tendency is to be left handed 
in order to meet every day situations which are constructed usually for 
the right handed person. Although Parsons' contentions are inter- 
esting, they are not adequately proved. His idea presupposes that 
the eye mechanism functions before the muscular mechanism of the 
hands and arms. It would be interesting to know in this connection 
how congenitally blind individuals compare with normals in preferential 

The most important contribution to the whole field of cerebral domi- 
ance has been made by Smith (202). We should like to present a 
quotation from his work since it tends to disprove most of the con- 
tentions set forth by the previous exponents of the theory of laterality 
and cerebral dominance: 4 

"Another aspect of the theory of lateral cerebral dominance which is 
contradicted by the results of this study is related to the effects of 
section of the corpus callosum upon language functions. In the theories 
advanced by Orton, and Travis, speech disturbances as well as other 
types of psychological dysfunction are accounted for in terms of lack of 
dominance of one hemisphere. It is supposed that the absence of 
specific dominance in some cases gives rise to motor blocks which are 

4 Smith, Karl U. Reprinted by permission of J. Gen. Psychol., 1945, 32, 76-77. 


evident especially in the complicated motor adjustments of speech. 
The present observations, including as they do data on a fairly large 
sample of individuals in whom the neural connections basic to inter- 
cortical integrations have been abolished, provide an adequate basis for 
an evaluation of this hypothesis. Speech disorders were not evident in 
any of the patients subsequent to section of the commissural pathways 
of the corpus callosum. One patient stuttered as a child and had a 
recurrence of this defect in combination with aphasic signs after a brain 
abscess, which occurred some three years prior to this experiment. This 
man's speech became neither better nor worse after complete division 
of the pathways of the corpus callosum. Case 13 displayed before 
operation a tendency to stutter under emotional excitement. He could 
speak very well on the day after operation but his speech blocks during 
emotion were later evident. These observations seem to prove that 
speech functions are independent of intercortical integrations which 
may be mediated by the commissure systems at this level. Accord- 
ingly, it may be questioned whether or not cortical dominance and 
subordination are related to the phenomena of stuttering and speech 
dysfunction as intimately as has been suggested. 

It is the opinion of the writer that the results of the experiment point 
toward a comprehensive revision of all present ideas about cerebral 
dominance and intercerebral coordination of function. They prove 
without much question, that the concept of lateral cerebral dominance 
as it has been variously modified to explain facts related to laterality in 
behavior, has been improperly interpreted. In terms of this experi- 
ment, it cannot be asserted that the commissure systems of the hippo- 
campus and the anterior commissure take over the functions of the 
callosum in its absence, for it has been shown that the motor organi- 
zation of the individual is not greatly changed by the section of these 
pathways in conjunction with partial and complete division of the 
fibers of the callosum. As far as the neural basis of laterality and its 
relation to cortical dominance and subordination is concerned, it seems 
likely that, if any kind of cortical or cerebral dominance exists at all, it 
has very little significance in determining sidedness in comparison to 
inequalities of function that must exist at lower levels in the nervous 

The neurological concept of lateral cerebral dominance logically is 
based upon the fact that lesions in one hemisphere, contralateral to the 
preferred side of the body, generally produce symptomatic disturbances, 
such as speech dysnfunction, which are not found as a result of similiar 


lesions occurring in the other hemisphere. This view seems to be 
fairly well supported by facts in human neurology, not only in respect 
to speech functions (Weisenburg) but also in regard to some perceptual 
activities. No evidence is provided by the present observations in 
support of or in contradiction to this view. But it is clear from this 
study that the predominant significance of one hemisphere in motor and 
perceptual capacities is not based upon direct neural connections between 
the two cortices of the brain, as provided by the corpus callosum or other 
cortical commissures. Presumably, therefore, lateral cerebral domi- 
nance must rest upon imbalance in function at levels below the cortex, 
in which interaction between two sides of the system is important, or is 
the result of explicit anatomical localization on one side of the cortex 
of certain complicated speech and perceptual functions. It seems clear 
that direct neural interaction between the two cerebral cortices carried 
out by commissural fibers is not indispensable for the development of 
maintenance of this functional localization." 


The symptoms of stuttering are numerous and varied. The first 
of these symptoms is the manifestation of repetition of speech sounds 
and blockings in the attempt to speak syllables, words, or sentences. 
Other manifestations which may to a certain degree be observable 
are detectable by laboratory methods. The primary derangements 
of the speech mechanism include disturbances in breathing, control 
of the abdominal and thoracic movements, control of larynx, control 
of tongue movements and the muscles of the jaw. Records of dis- 
turbances of the above mechanisms have been made by many investi- 
gators. The methods employed for this purpose need not be discussed 
here, although it may be noted that the pneumograph and galvanometer 
have been most frequently utilized. The results of these investiga- 
tions show rather clearly the lack of synchronism between the various 
parts of the speech mechanism. Different cases present different 
types of lack of synchronism. Strother and Kriegman (201) disagree 
with the general conclusion that stutterers suffer from a general ar- 
rhythmokinesis since they found that stutterers could reproduce as well 
as normal subjects a given rhythmic pattern with movements of the 
jaws, lips, tongue and forefinger. 

The lack of complete understanding of the causal factors in asyn- 
chronism has led to different theories and types of therapy. These 
therapeutic measures call for exercising of the part of the mechanism 
asynchronized. Asynchronization in stuttering does not occur because 


of a pathological condition of the central nervous system, but must be 
explained by some functional disturbance, so that these various muscle 
groups are innervated in an irregular order. The muscles of speech 
respond then in a nonrhythmical incoordinated fashion. 

Stutterers show many physiological disturbances and muscular in- 
coordination of other parts of the body. According to Gardner (203), 
the balance of such delicate muscles as those of the pupil of the eye tends 
to be affected during the speech spasm. Since the hands and arms are a 
medium of communication, disorders might be expected to occur in the 
function of these members. Travis (204) and his co-workers have found 
that the rate of tremor movements of the hands is different for the 
normal and the stammering subject. These involuntary movements 
are ordinarily under cortical control. Since they are modified in stut- 
terers, the investigators have concluded that the cortical control must 
be modified. The innervation of the 2 arms in the right handed 
subject during voluntary contraction is found to take place in the right 
arm first, followed by innervation of the left arm. In stutterers, the 
order of innervation is varied, occurring frequently in the nonpreferred 
arm first or simultaneously in the 2 arms. In a study of mirror draw- 
ing, it has been found that right handed stutterers do much better with 
the left hand than they do with the right. This is in direct opposition 
to the results found in the normal individual. All of these facts, ac- 
cording to Travis, point to the lack of cerebral dominance in the case 
of left handed individuals. He offers these experiments in support of 
the theory mentioned earlier. These phenomena are concomitant with 
the speech defect and are not necessarily etiological factors. The same 
explanation will suffice for both the speech aberration and the muscular 

Vasomotor changes and changes in the psychogalvanic response ac- 
company stuttering. That these changes precede the onset of the 
speech attack is doubtful. They are more probably symptoms of a 
general emotional disturbance. Certainly both kinds of response occur 
in normal emotional situations, and no speech difficulty is encountered. 
Just why they should be so important under certain circumstances and 
not in others is not clear, unless still other physiological or psychological 
conditions are the controlling causes. Robbins (205) reports that there 
is a congestion of blood in the brain during stammering. This was 
observed in a patient with a trephined skull. The volume returned to 
normal when speech occurred without stammering. The significance 
of this observation must be evaluated in light of the above discussion. 



The theories advanced for explaining stammering and stuttering are 
closely associated with the various symptoms ascribed to these defects. 

The following list includes the majority of the theories. 

1. Dunlap's Theory of Vocabulary Taboo. 

2. Fletcher's Theory of Fear Conditioned by Social Situation. 

3. Travis's Theory of Reduction of Cortical Dominance. 

4. Bluemel's Verbal Image Theory. 

5. Swift's Visual Central Asthenia Theory. 

6. Adler's Inferiority Theory. 

7. Psychoanalytic Theory. 

8. Imitation Theory. 

9. Various Anatomical Theories. 
10. Various Physiological Theories. 

Dunlap's theory has already been discussed (page 115) in explaining 
sex differences in stuttering. Travis's theory has also been stated 
(page 1 19) in the discussion of eyedness and handedness. These theories 
will not be commented on further at this point. 

Fletcher (206) has stressed the importance of social situations in the 
etiology of stuttering. The following quotations from Fletcher will 
aid in understanding his point of view. He says, "All communication 
demands a social adjustment, either intellectual or emotional, or else 
both at once." "The stutterer's adjustment, therefore, is not unique in 
being of a social character. It is unique only in that it invokes an 
exaggeration, or morbidity of certain factors of social adjustment, 
especially those of feeling attitudes." He does not limit his concept to 
include only fear of using tabooed words as did Dunlap. He includes 
any emotional condition which arises from the realization of the social 
relationship between speaker and auditors in which anticipation of 
possible unpleasant consequences of failure to meet these social adjust- 
ments is the predominating element. 

In support of this theory, Fletcher has pointed out instances of per- 
manent and temporary disappearance of stuttering when the social 
situation has been modified. Distraction and the removal of conse- 
quences of the failure to meet a social situation will serve this purpose. 
Some individuals can swear or sing, although they cannot speak, without 
stammering. In these forms of communication, there is a change in 
the social relation between the speaker and auditor, or else other emo- 
tional factors such as occur in swearing dominate the usual relations 


involved in speech. The ability of stutterers to read and speak while 
alone, or when they believe they are alone, adds additional evidence to 
the concept of social interaction. For example, some stutterers can 
speak normally into the transmitter of a telephone when the receiver 
is left on the hook. As soon as this is removed by another person, dis- 
turbed speech reasserts itself. 

Eisenson and Wells (207) corroborated experimentally this notion of 
Fletcher. They introduced an element of responsibility in communica- 
tion in choral reading and found that there was an average increase of 
60 per cent in stuttering spasms over that found in the same group 
in choral reading when carried on without responsibility. 

Fletcher also calls attention to the teacher who speaks normally when 
teaching but who stammers when he assumes the role of student in the 
summer time. There is in this case a complete change in the social ad- 
justment required. The writer wishes to call attention to a case which 
he saw after the lapse of about 4 years. This college man stuttered 
quite badly at the time he left college. In the interim he had been 
stationed in South America, where he acquired a speaking knowledge of 
Spanish. While speaking Spanish, the speech defect disappeared, but 
upon his return to this country the speech difficulty reappeared. The 
speech defect reappeared, however, only when he attempted to talk 
with someone who knew him previous to his going to South America. 
Self consciousness and embarrassment arising from old social situations 
were sufficient to reinstate his old speech habits. 

Blanton (208) has attempted to analyze the fear factor rather than the 
failure of the social adjustment. Among a group of soldiers studied, 
6 began to stutter with service at the front; 7 were stutterers who re- 
lapsed with service at the front; 6 who had stuttered previously re- 
lapsed with service in this country when confronted with a dangerous 
situation such as a fight, a runaway horse, and a narrow escape from 
an explosion. 

The theories of Bluemel and Swift may be grouped together, since the 
underlying assumptions of both are quite similar. Bluemel assumes 
that the stutterer's difficulty is due to transitory auditory amnesia. 
The individual cannot reproduce a sound or word because he or she has 
no auditory image of the sound to be reproduced. Swift's (209) theory 
is essentially the same except that he attributes the inability to speak 
correctly to lack of visual imagery. These theories deny the primary 
role of embarrassment and fear and state they are only secondary. 
They further assume, especially Bluemel, that the temporary auditory 


amnesia is the result of circulatory changes in the brain which produce 
congestion or anemia. Swift places more emphasis on a general weak- 
ness for visual imagery than he does upon a temporary condition. The 
basis for their assumptions has been a study of the imagery of stammer- 
ing and stuttering cases. Both claim to have found by means of ques- 
tionnaires that individuals who have these speech defects are weak in 
auditory imagery or visual imagery. Both theories are open to criticism 
on a basis of the methods employed for determining imagery. Both 
are open to a more serious criticism in that they have to assume that 
the motor responses are dependent upon and are similar to the ideas 
which initiate them. The whole theory of ideo-motor activity has been 
questioned and to make it the sole agent for the fine adjustments neces- 
sary for speaking seems to be stretching the point. 

Bluemel's (210) view on the importance of auditory amnesia in stut- 
tering seems to be altered to a considerable extent in his later writing. 
He has adopted conditioning (conditioned reflex theory) as a general 
explanatory principle. His theory does not differ greatly from that of 
Fletcher, except that he emphasizes causes other than the social situa- 
tion in the conditioning and couches his theory in conditioned reflex 

The inferiority theory of Adler (211) and the psychoanalytic theories 
may well be considered together. These theories assume that the speech 
difficulty arises because of some marked anxiety due to unconscious 
emotional complexes. The nature of these depends upon the school 
with which the analyst is identified. Some points of the psychoanalytic 
theories do not differ appreciably from those set forth by Dunlap. 
While Dunlap maintains the acquisition of obscene and swear words 
leads to hesitation in speech, he insists that they are conscious factors. 
The analysts, on the other hand, insist that the memory of these words 
or desires tabooed by society are repressed. The repressed memories 
center in sex words and sex acts to a large extent in the concepts of the 
analysts. Coriat (212) even goes so far as to maintain that infantile 
oral eroticism with its accompanying sucking movements and pleasur- 
able sensation is the basis for these speech defects. In other words, 
he has to postulate a repressed stage of infantile oral eroticism for 
stutterers. Whenever an individual who has a repressed condition of 
this kind begins to talk, certain movements of the mouth are comparable 
to the erotic movements and result in the reestablishing of the emotional 
situation which accompanied the erotic act. Certainly it may be ques- 
tioned with propriety whether all stutterers have gone through a stage 


of oral eroticism and if they had, whether any emotional situation was 
aroused that would produce all the secondary symptoms accompanying 

Adler's inferiority theory does not lay so much stress upon the sex 
element. He assumes that stuttering is a compensation for a deficiency. 
It is the method by which a particular type of personality asserts his 
"ego." Satisfaction is secured; the individual obtains superiority or 
sets himself off from the group by punishing himself. The affliction 
enables the stutterer to say that he would be great or that he would 
accomplish much greater things if it were not for the handicap. The 
only difficulty with this theory is that stutterers cannot be shown to have 
a feeling of inferiority except in regard to their speech. This feeling 
concerning speech may be the result of their inability to speak correctly 
rather than the cause of it. Meyer (213) (214) from clinical studies of 
stutterers fails to find evidence of inferiority but does think there is good 
evidence of anxiety and schizoid traits. His idea is that stuttering is a 
conflict between a conscious desire to speak and an unconscious desire 
not to speak, as is exemplified by the classical stuttering of the marriage 
proposal. The foundations of more deeply rooted stuttering may be 
traced to the child's failure to attain oral satisfaction, leading to pain, 
anxiety and hunger with attendant verbal aggressiveness which is 
dangerous before feared persons. 

Some people attribute stuttering to imitation. It is probably true 
that a few individuals do begin to stutter from hearing other people. 
Imitation will not explain why they imitate incorrect speech rather 
than correct speech. Since there are more people who do not stammer 
than those who do, everyone is exposed more to correct speech habits. 
Johnson (215) has made an interesting observation on the Bannock and 
Shoshone Indians. He was unable to find evidence of stuttering; 
furthermore, the language contained no word for it. He suggests there- 
fore that semantic environment may be a causal factor. This inter- 
pretation has some of the elements of suggestibility as a factor and is 
therefore mentioned along with imitation. 

The anatomical theories have been limited only by the various 
mechanisms involved in speech. The tongue, teeth, nasal passages, 
and other parts of the speech mechanism have been altered in numerous 
ways in order to test out these theories. Unfortunately these changes 
have little to do with stuttering, although the distraction brought about 
by the changes is sufficient in some cases to cure the speech defect. 
Physiological theories involving breathing, vasomotor changes, and 


differences in endocrine secretions do not offer any better results. The 
stutterer manifests many alterations of these functions during his ab- 
normal speech, but does not exhibit any decided differences when not 
stuttering. These are symptoms of stuttering and not etiological 

Gordon (216) has attempted to show that the stammering symptoms 
are linked up with still other forms of aberration. His studies indicate 
that stammerers frequently have symptoms common to allergic dis- 
turbances and that many of the stammerers also suffer with enuresis. 


The therapy for stuttering has undergone a variety of changes, 
although the old method of Demosthenes seems as effective as some of 
the other methods suggested and used. Distraction has received much 
attention as a therapeutic method. In many types of therapy, ordi- 
narily called organic, the sole efficacy has been in distraction. Demos- 
thenes's method of holding pebbles in his mouth and allied methods of 
cauterizing the tongue, cutting the tongue in various ways, cutting of 
the branches of the glossopharyngeal nerve, paying strict attention to 
breathing, and applying bitter substances to the oral cavity have all 
been successful in curing some cases. Most of the cures have been 
effected because attention has been directed away from the fear of 
speaking and its consequences. Another method of curing stuttering 
which involves distraction to a certain extent, as well as conditioning, 
is that of performing some act, such as beating time with each spoken 
word. This may be done in time with a metronome or in rhythm with 
the hand movement of the subject. When attention is directed to 
beating time, it cannot be placed on the speech process. The condi- 
tioning aspect of this method is analogous to Pavlov's conditioned 
reflex. Since most stutterers can beat time with a metronome without 
difficulty, it is assumed that if a word is spoken with each beat, this 
time sequence or rhythm can be established definitely through practice. 
Later the beating may be dropped. Unfortunately, the method fre- 
quently leaves other muscular habits which are as bad if not worse 
than the original defect. Suggestion, either direct or indirect, and 
hypnosis will bring about cures in some patients. If the stutterer has 
confidence in the doctor or in the speech instructor, a statement that 

6 For a more extended survey of this area, the student is referred to Speech Correction; 
Principles and Method, by Charles Van Piper, 2nd ed. Prentice-Hall, New York, 1947. 


the subject will no longer stutter is effective. Certain quacks ap- 
parently succeed by bullying the individual. Various people have 
reported cures of stammering and stuttering by means of hypnosis. 
The general technique is to hypnotize the patients and give them post- 
hypnotic suggestions that they will not have any difficulty when they 
awake. The technique is not quite as simple as has been stated, but 
this description of it suffices for our present purposes. The efficacy of 
this method may lie in bolstering up the individual's self confidence. 
Most subjects can speak correctly if a brief time limit is given at first 
in a post-hypnotic suggestion. Once they find that they can speak 
correctly, this enables them gradually to carry on the process in all 
their speaking. 

The next method which needs consideration is applicable only to 
those cases where a strong emotional shock has produced the speech 
difficulty. This type usually develops almost immediately following 
the traumatic condition. Psychoanalysis or hypno-analysis may be 
satisfactory methods of discovering the source of the difficulty. Taylor 
(217) and McDougall (218) both cite instances in which the emotional 
element has been discovered by means of hypnosis. A case cited by 
McDougall points out clearly the factors that operate in establishing 
this variety of stuttering. A young soldier, with a strong religious 
tendency as a result of strict training, was buried by an exploding shell. 
Just before losing consciousness he swore violently. He stuttered when 
he regained consciousness. During hypnosis he was carried back to the 
original incident and memory was entirely recovered for the lost events. 
His speech defect also disappeared. This case demonstrates that the 
symptoms exhibited may be referred back to incompatibility of feelings 
centered in his early religious training. 

Adjustment of the environment has been most strongly advocated by 
Fletcher for relieving stuttering. In some instances, this is practical; 
in others, it is not. Most of the difficulty occurs with parents and 
teachers who attempt to correct speech difficulties by punishment or by 
continually calling attention to them. This treatment usually accentu- 
ates the condition. Class recitation does not usually aid stutterers, 
since it makes them the center of jibes from the other pupils. This may 
result in withdrawal from many other group activities. Since they 
cannot be segregated in many schools, the problem of handling them is 
exceedingly difficult. More tact is usually required than the average 
untrained teacher possesses. Any situation which involves the least 
embarrassment should be utilized for allowing the individual to express 


himself. These situations have to be determined for individual cases. 
The writer wishes to cite, in this connection, the case of a stutterer 
which he has observed. 

Girl twins about eighteen years old were in college together. The 
one took a very active part in college life and was a good student; the 
other was socially very agreeable, but not so active in college life and 
was not such a good student. The latter stammered. In working with 
this patient it was found that the parents constantly favored the first 
one mentioned. She was given charge of spending money and allowed 
to make almost all decisions for the other one. There was a gradual 
onset of stuttering, which was accentuated by constant parental at- 
tention. The parents were advised to send the girls to different schools, 
and a few other therapeutic measures were instituted. The stutterer 
showed considerable improvement from this change. Later, the girl 
married and moved to a different section of the country. . Her speech 
problem, in the meantime, has disappeared. This case and the case 
cited earlier of the man who had little difficulty in speaking Spanish 
indicate clearly the importance of environmental influences. 

Dunlap (219) has suggested a method of treating stuttering that is 
different from any advanced in the past. He advocates having stutterers 
stutter in order to rid themselves of this difficulty. Actual treatment 
by this method should not be undertaken by anyone who is not 
thoroughly acquainted with it. The psychological implications of the 
method are as follows: 

Stuttering is an involuntary form of response and, since it is involun- 
tary, cannot be controlled by voluntary influence. The way in which 
this voluntary control is secured, is to practice making the response with 
the idea that the response will disappear or will be brought under volun- 
tary control. This method has been successful in treating some cases 
of stuttering and in breaking other bad habits. Whether it will be 
effective in the case of traumatic stuttering cannot be said for the 
moment. Case (220) in working with this method, found that it was 
desirable to consider two types of stammerers, (a) those occasioned by 
a strong emotional blocking which still persists and (b) habit residual 
cases that were originally induced by emotional conflict which has 
disappeared. He felt that the negative practice technique was particu- 
larly effective with the latter group, whereas a combination of therapies 
was desirable in the former group. Recently the use of electric shock 
has been employed in the treatment of stutterers. The results are not 
uniform. This may be expected since the treatment of psychoneurotics 


generally by electric shock has not been too satisfactory. There are 
two possible explanations for whatever efficacy is claimed: (a) the 
shock destroys the underlying anxiety condition, or (b) the stuttering 
is the most recently formed speech habit and the more recently acquired 
responses are eliminated in some manner by electric shock. Owen and 
Stemmerman (221) think that the shock makes the patient more amen- 
able to psychotherapy and to speech reeducation. 


In addition to vocabulary acquisition, delay in speaking, stammering 
and stuttering, there are many other disorders. Travis (222) lists 7 

Distribution of various types of defects in 70,000 cases 

Sound substitution 4, 623 . 8 

Stuttering 2,214.96 

Oral inactivity i , 146 . 44 

Structural articulatory 860.02 

Dialectal 575-64 

Functional voice 230.67 

Structural voice 181 .38 

Hard of hearing 80.69 

Paralytic articulatory 49 . 28 

Paralytic voice 0.17 

major groups with 43 subdivisions, Bridges (223) gives 13 special 
disorders with many variations. These will not be treated in detail 
and a selection will be made of the disorders which are treated. At the 
White House Conference on Child Health and Protection (224) the 
frequency of occurrence of various speech disorders was presented. 
This information is given in table 13. This table indicates, then, that of 
10,000 speech defectives about 22 per cent will be stutterers, and less 
than i per cent will suffer from aphasia. An examination of the classi- 
fication used reveals the prevalence of both functional and organic 
types. ^ 

Lisping is one of the defects with which most persons are familiar. 
Lispers tend to pronounce the sibilant letters like linguals, especially s 
as th. It is frequently attributed to faulty movements of the tongue, 
but may be due to any one of a number of organic causes. The shape of 


the oral cavity, the size of the tongue, weakness of the muscles of the 
tongue and partial paralysis of the lips may be counted among the causal 
factors. Corrective exercises for articulation or operations may be 
tried therapeutically in some cases. 

The paretic and paralytic speech represent disorders resulting from a 
total lesion or partial lesion of the central nervous system. Cerebellar 
lesions produce slowness, drawling, monotony, with a tendency toward 
staccato. The speech may be irregular and jerky. This speech is 
found in multiple sclerosis and after injury to the vermis. Cerebral 
lesions produce slurring, indistinct, and thick speech. Patients with 
dementia paralytica exhibit slow, halting, uncertain, stumbling and 
irregular speech. Lesions of the corpus striatum produce monotonous 
explosive speech. At times the voice becomes shrill and high pitched. 
The speech of the patient with paralysis agitans may be of this type. 
Pyramidal lesions in the medulla are usually bilateral. These lesions 
may be due to vascular hemorrhage or sclerosis of the pyramids involv- 
ing the hypoglossal, facial and accessory motor nuclei. Difficulty in 
speaking becomes progressively worse as the lesion increases. Much 
effort is expended in trying to talk. Mutism is a disorder of speech 
which superficially may resemble paralysis. Patients who sufter from 
this are quite capable of speaking but will not. The etiology is linked 
with hysteria and schizophrenia and will be discussed later. 

Other patients with mental disorders exhibit speech anomalies that 
have been classified under still different headings. Aphonia, echolalia, 
verbigeration, verbomania, pseudolalia, and neologisms are types that 
may be encountered. 

Aphonia is a weakened whispering speech often encountered in hysteria 
and anxiety cases. One hundred sixteen cases of war aphonia were 
studied by Sokolowsky and Junkermann (225). They found the pre- 
cipitating factor in most cases was a cold, sore throat, or laryngitis. 
The underlying cause is usually to be found in an attempt to escape 
from a problem for which the patient could find no solution, according to 
Risemann and Aagesen (226). One patient seen by the author was a 
female college student, referred because the teachers could not hear her 
in class. The cause seemed to be her inability to cope with her home 
environment. She learned of an extra-martial affair of her mother and 
became afraid lest she reveal her knowledge to her father. When 
removed from the home environment, her speech rapidly returned to 


Echo reactions or echolalia may occur under the following conditions: 

1. Aphasia of the transcortical type, and advanced dementia 

2. Low grade mental deficiency 

3. Chronic epilepsy 

4. States of clouded consciousness 

5. Catatonic states 

6. Early speech development in childhood 

7. States of fatigue 

It is usually brought about by impairment of cerebral functions in 
pathological cases; by discrepancy between strong impulse to speak and 
poor ability to understand in children; by attempt to understand spoken 
words (reinforcement) in other cases; and by simple imitation in still 
other cases. 

Verbigeration is the repetition of the same word or sentences. This 
corresponds in a way to the obsessional and fixed ideas of certain psy- 
chopathic individuals. Verbomania is excessive use of words or gar- 
rulity. The chattering of some women has been described as belonging 
in this category. Pseudolalia is applied to the production of meaning- 
less sounds. This has been applied to all forms of defective speech 
other than stammering and stuttering. The intepretation of "mean- 
ingless" leads to some difficulty, since some speech sounds may be 
meaningful to the speaker but meaningless to the auditor. Baby 
speech and sounds of idiots have in all probability a meaning for the 
user. Neologisms are the use of high sounding and misapplied words. 
They are frequently manufactured for the occasion. The stories at- 
tributed to negro ministers and the stories of Octavus Roy Cohen 
illustrate this type of speech. 


The aspects of communication which are yet to be covered are those 
of gesture, writing, aphasia, and apraxia. Aphasia and apraxia are 
closely linked with the association process and will be discussed in a 
later chapter. Automatic writing and certain forms of dissociated 
speech may be treated more effectively at the same time. 

There are found in written communication, aside from the kinetic 
disorders mentioned earlier in the chapter, disorders such as grapho- 
mania, pseudographia, and mirror writing. Graphomania is the tend- 
ency to write great quantities of material. Many dementia patients 
have this tendency. It may be a substitute means of expression where 



vocal communication is hampered. Normal examples of this type of 
activity can be found by examining the telephone book, note books of 
students, and desks or tables. It is sometimes considered as a disso- 
ciated activity. When the written symbols are meaningless the activ- 
ity is termed pseudographia. Scribbling of children up to the age of 
four or five may appear to the adult to be meaningless but it is not for 
the child. The same difficulty is encountered here in interpreting sym- 
bols as meaningful as was encountered in pseudolalia. Schizophrenic 


OC Too /Poo 7?oo ~To 60 


15 HfGH 

To Art Aoo 

FIG. 24. Drawing of a schizophrenic patient. 
ity of symbolization are typical. 

The coinage of characters and the unreal 

patients are wont to express themselves by strange and bizarre symbols. 
Contained in their writing will be found stereotyped expressions, neo- 
logisms and various combinations of symbols. An example of this kind 
of writing appears in figure 24. 

In figure 25 an example of paretic writing is presented. The incoordi- 
nation, lack of coherence, and omission are typical of the lack of muscu- 
lar control and the mental ability of the individual. Quinan (227) in 
comparing the writing of 148 paretics with 200 normal persons found 




that they wrote more slowly, omitted more words and gave the line an 
upward slope. The etiology of this type of writing is similar to the 
etiology of the paretic speech and gait. 

Other psychopathic patients tend toward certain types of writing. 
The depressed patients (involutional melancholia and the manic depres- 
sive in the depressed state) show a slowness and deliberation in their 
activity. Their writing may be small and very precise as illustrated in 
figure 26. In contrast with these, the hysterical and paranoic patient 
may show a style with flourishing and flowing letters. The former 
patient tends to do quite a bit of underlining. Paskind and Brown's 
(228) work shows that the letters of the words are taller for deteriorated 
epileptics than for non-deteriorated epileptics. This is explained on 
the basis that children tend to write larger than adults and that the 
centers controlling writing of the deteriorated patients never attain 

FIG. 16. Reproduction (actual size) of writing by a patient with involutional melan- 
cholia. Small precise writing is characteristic of many ofthese patients. 

full maturity. Muhl (229, 230) has investigated handwriting and 
automatic writing as a possible means of discovering sources of conflicts 
and classifying psychopathic patients. 

The sample of printing in figure 27 is typical of that done by some 
children in the beginning stages of writing. This form of mirror writing 
is abnormal when found in adults. The explanation for mirror writing 
is not very clear. It is assumed that the child has not yet grasped the 
significance of all the signs of space perception. It is quite possible 
that the child recognizes the difference in the spatial relations but sees 
no reason for changing his own procedure. A description of a case of 
this kind is presented by Billings (231). Morlass (232) postulates a 
disturbance of cerebral dominance to account for mirror writing in 

In communicating, meaning is partially conveyed by gesture. Some 



languages depend upon this more than others do. The Latins use 
gesture much more than do the English. The usual jokes about the 
Hebrews and French employing gesture point to stock and language 
differences. The use of gesture is normal; some individuals carry it to 
an extreme. This is designated as hypermimia and may be the result 
of vocabulary impoverishment. It may be attributed to weakness of 
the speech mechanism or to faulty training in speaking. The use of the 
wrong gesture is called paramimia. There are certain characteristic 
gestures applicable to communication that are as definite as words. 
Pointing a finger or pounding on the table will be understood always as a 
gesture of emphasis. The acquisition of proper gesture depends upon 
environmental influence and training. Organic disturbances which 



FIG. 27. Typical example of mirror writing. The word MARK was written in the 
directions and order indicated. 

aftect the sequence of muscular movements may cause improper gesture 
due to lack of synchronization of various muscle groups. 


Motor disorders connected with the elimination processes of the 
organism have not usually been accorded recognition. Both urination 
and defecation are subject to disorder that may be of organic or func- 
tional origin. Aside from the inconvenience and embarrassment that 
are associated with such disorders, they may be symptomatic of other 
disorders or may cause other organic disorders. The control of the 
muscles of the anus and bladder is through nerves in the inferior mesen- 
tery ganglion and the pelvic ganglion (parasympathetic system). In 
early life, the bladder and bowels empty automatically, but with the 
development of the pyramidal tracts and training, the muscles are usually 
brought under voluntary control. The cortical center involved in this 


voluntary control is probably in the anterior central gyrus. There are 
also probably infracortical controls since some pyramidal lesions do not 
cause loss of control, whereas others may result in difficulty in inhibiting 
or initiating urination. 

Obviously weakness or paralysis of the sphincter muscles will result 
in inability to retain fecal matter or urine. Similarly, faulty innervation 
through the reflex system, which is initiated by distension of the bladder 
or rectum may result in loss of control of the sphincter muscles so that 
they will be relaxed too readily or be contracted too much. Unques- 
tionably habit and ideational factors play an important role. These 
disorders will be discussed more fully in a later chapter. 



(Topographical and Cytoarchitectural Relationships) 


In the preceding chapters we have discussed the disorders arising from 
sensory and motor difficulties. We are confronted at this point with 
the problem of tying these groups of disorders together through the 
central nervous system. It will become progressively apparent that 
structure and function are dependent upon each other. There are, 
however, many symptoms that are only indirectly related to the organic 
defect (structural defect) since symptoms not caused directly by the 
organic defect may be the means by which the organism responds to the 
damage. Symptoms are, however, related to dysfunction and dys- 
function is in turn dependent upon organic involvement. 

There are at least 5 major types of agents that produce pathology of 
the brain: 

A. Trauma (severance of nervous tissue by mechanical insult) 

B. Exogenous toxic agents (alcohol, lead, bromides, carbon monoxide, 


C. Endogenous toxins created by disease (typhoid, encephalitis, men- 

ingitis, etc.) 

D. Circulatory or blood conditions (arteriosclerosis, embolism, hemor- 

rhage, etc.) 

E. Neoplastic conditions (tumors, thickening of meninges) 

These various agents do not lend themselves equally well in working 
out the localization of functions of nervous structure. The effects of 
the agents in groups B and C are more likely to be generalized than 
specific, and this is partly true of circulatory or blood conditions. The 
effects of hemorrhage and embolism may, however, be relatively well 
localized. Tumors may be definitely localized, but pressure exerted on 
other parts of the neural structure or the interference with the circulation 
of non-involved structures may complicate the picture. 

Our best sources of information, then, come from either experimental 
or accidental destruction of portions of the brain. It is obviously 



impossible for us to include all the material that the student would 
derive from a course in neurology or clinical neurology, but this general 
survey will serve as an introduction to the general status of the field. 


The effects of lesion or destruction of brain tissue are best known from 
experimental ablation in animals, experimental ablation in humans on 
whom no other method of therapy is available, and accidental brain 
damage which was quite frequent in the war. One of the major problems 
that arises is whether specific topographical (gross superficial) areas con- 
trol specific psychological functions. Another of the major problems is 
how the cytoarchitecture (tissue composed of cells of similar size, density 
and shape) is related to specific function. We shall discuss primarily the 
first of these topics since relatively little is known about the clinical 
manifestations of disorders of cytoarchitecture of the brain. The 
correlation of histopathological conditions and psychological disorders 
is fraught with many difficulties and has aroused many differences of 
opinion. These differences are exemplified in part in Lashley's work on 
mass action versus localization of function. Lashley (233) has sum- 
marized the experimental work related to the theories of localization and 
mass action. He has also presented some of his original work in his 
book entitled Brain Mechanisms and Intelligence. Holding the ex- 
treme point of view of nonspecificity of function, he 1 says (234) : "The 
most surprising outcome of the work has been the number of lines of 
evidence pointing to the equivalence of function of all parts of the 
cerebral cortex for learning. When the first study of mass relations 
was undertaken, I fully expected to obtain varied results from lesions 
in different areas, exhibited both through unlike effects upon the rate of 
learning and through qualitative differences in the solutions adopted by 
different animals. No indication of this has been obtained in any of 
the experiments. Selective effects upon habits already formed appear 
after diverse cerebral injuries, but in all tests upon learning subsequent 
to brain operation the effects of injuries to different areas seem to be 
qualitatively identical. There is no indication of a slower acquisition 
which can be related to the locus of injury, of one rather than another 
element of the problem." 

Cobb (235) in writing on the problem of localization states: 2 "Twenty 

1 Reprinted by permission from K. S. Lashley, Brain Mechanisms and Intelligence. 
University of Chicago Press. 

2 Cobb, Stanley. Reprinted by permission from Personality and Behavior Disorders. 
J. McV. Hunt, Editor. Ronald Press Co., 1944. 


years ago a wave of anti-localization disturbed the small pond wherein 
worked the specialists in cerebral function. The brain was said to be 
equipotential in function and clinical localization was belittled. The 
experimentalists, however, have enlarged their sphere, used more highly 
developed mammals (Fulton, 1938; Kluver and Bucy, 1939), and shown 
that the quite definite areas of functional localization on the cerebral 
cortex of man are phylogerietically predicted by less and less definite 
but still recognizable areas, all the way down the mammalian ladder. 
In short, rats show less specific localization and more equipotentiality, 
while man shows the opposite (Lashley, 1929). 'Centers' are still under 
suspicion, but 'areas' are quite proper." 

There is, moreover, another factor even with animals that has ap- 
parently been overlooked. If animals were subjected to operations 
before the various areas had become functionally connected, would the 
specialized areas then be capable of assuming functions that belong 
ordinarily to another area? It is highly probable that the equipoten- 
tiality of function is due to the use of pathways which have been oc- 
casionally traversed but which are not normally employed. 

Kennard (236) has thrown some light on this problem. From oper- 
ative data on chimpanzees, monkeys, and humans, it has been ascer- 
tained that less motor disorder results from an injury to the cerebral 
cortex at an early age. The infant possesses considerable capacity for 
reorganization that does not exist at later ages. A relative functional 
non-specificity of cortical areas in the younger age groups is partially 
responsible for this fact. 

Clinical observations of patients show rather clearly that the age at 
which lesions occur seriously influences the nature of the clinical symp- 
toms. While autopsies of encephalitis victims of different ages often 
reveal similar lesions, the symtomatology exhibited before death in 
older people differs from the symptomatology in younger people. The 
adults may have headache, fever, diplopia, and insomnia, with very little 
disturbance of emotional or intellectual functions. Children in addition 
to headache, fever, and insomnia, may show restlessness, inattention, 
impulsiveness, moodiness, and negativism. These differences may be 
due to the incomplete development of neural systems and the insta- 
bility of physiological processes in the younger age groups. The older 
age groups are less pliable in regard to reorganization and their response 
patterns are firmly fixed. 

Goldstein (237) believes that additional factors operate in controlling 
the disparity between symptoms (function) and changes in structure. 
He holds that there are four types of observable symptoms: (a) defects 


of performance; (b) symptoms due to the effects of separation of an 
undamaged area from a damaged one; (c) irradiation symptoms; and 
(d) symptoms which represent protective mechanisms against the 
effect of the defect on the total organism. 

(a) Defects of performance are not solely dependent upon the location 
of the lesion. While lesions of the posterior central convolution produce 
sensory loss and lesions of the anterior central convolution produce 
movement disturbances, the losses are not uniform, but there is rather 
a modification of performance which is manifested in a retardation 
of psychomotor activity. This characteristic holds true for all neural 
regions as well as psychological levels. In addition there is usually 
some loss of abstraction, (b) In the organization of the nervous system 
each part functions in interrelation with the whole. Activity arising 
from a localized area is therefore partially dependent upon the func- 
tioning of other areas, (c) Irradiation effects are somewhat similar 
to those in (b). Scar tissue (resulting from lesion) may arise in an area 
that is in functional relation with another area, and the two may repre- 
sent a functional unit. Impairment in either area would destroy the 
function of the unit as a whole. Goldstein (238) holds with respect to 
the symptoms under (d) that the organism has a fairly constant structure 
and a fairly constant function. When the individual is confronted with 
a task that he can perform, his performance and whole adjustment gives 
the appearance of an organism functioning at a normal level. This 
same individual when unable to accomplish the task confronting him 
may become fumbling, evasive, temperamental. His behavior pattern 
is one of considerable disorganization. Symptoms which may appear 
to stem from pathology are only a flight from the situations with which 
he is unable to cope and are a part of a protective pattern. 

We shall present at this point a summary of the results of damage to 
the gross topographical areas of the brain. The topographical arrange- 
ment is presented in figure 28, and the architectonics are shown in 
figures 29 and 30. Since we have much information related to the 
visual area of the occipital lobe, this area will be discussed first. 


It has been known since about 1800 that sensory functions are repre- 
sented in certain parts of the sensory cortex and that destruction of 
certain relatively well-defined areas in the brain would produce a loss 
of the corresponding senses. These observations were established from 
the work of Flourens, Hitzig, and Minkowski. This earlier work has 
been extended by investigators such as Lashley (239), Franz (240), 


Poljak (241), Holmes (242), Marquis (243), Kluver (244), and Smith 
(245). Work on tracing the sensory cortical pathways has produced 
very good results with regard to understanding the neuro-antaomy of 
the occipital lobes, but the mediation of various functions is not nearly 
so well understood. Tests for sensory impairment involve discrimin- 
ation, judgment, memory and learning, and in many situations the 

OL uproar BULB 

FIG. 28. Left cerebrum and cerebellum. Anatomical details in italics, functional de- 
tails in roman capitals. 

problem of what areas and what levels of the neural structure are in- 
volved is not at all precise. For example, Lashley (246) has shown that 
the simple brightness discrimination habit may be formed by rats in the 
complete absence of the cortical visual areas. The question arises, 
then, as to what areas are now serving this function. Freeman and 
Papez (247) have suggested subcortical areas. Their experiments with 
injury through the colliculi and posterior level of the thalamus, and 
Kapper's experiments on the thalamus show that lesions in these areas 
influence adversely the formation of the brightness discrimination habit. 




General Area 
Frontal Lobe 

FIG. 29. Cytoarchitectural map of the human cortex, convex surface (after Brodmann). 
Reproduced by permission from O. S. Strong and A. Elwyn, Human Neuroanatomy, 
Williams & Wilkins, 1943, p. 360. 

Key to cytoarchitectural maps* 
Brodmann's Area Name and/or Function 

4. Motor; so-called Voluntary' motor areas 

5 Premotor; extrapyramidal motor areas (there are 

others also) 
8 Frontal eye field; motor for eyes 

Prefrontal; frontal association areas 

Broca's area; premotor area for face, speech 

Postcentral area; somatic sensory functions 


Superior Parietal [-parietal association areas 

Inferior Parietal J 

Primary acoustic area 

Parietal Lobe 

Temporal Lobe 
Occipital Lobe 


9, 10, 11, 12 
3, 2, i 


41, 42 
possibly also 22 




Striate cortex; primary visual _ area 
Occipital area; visual association area 
Preoccipital area (strictly speaking this is in the 
parietal lobe); visual association area 

Probably sensory areas for taste and smell 

* We list here only those subdivisions which are fairly well established and are of 
physiological significance. 

Ghiselli and Brown (248) in discussing this problem state that "the 
brightness discrimination habit can be formed in the absence of any 
(but not all simultaneously) 3 of the primary visual structures." That 

3 Writer's insert. 



this view will hold for all visual functions is of course doubtful. Lesions 
in area 17 (figure 29) which is the receiving point for visual stimuli result 
in disorders such as anopsia, hemianopsia, and scotomas, which were 
discussed earlier. Contiguous areas 18 and 29 (figure 29) are involved 
in more complex visual processes such as recognition of visual objects, 
form, distance, and movement. More will be said of these disorders in 
our discussion of agnosia. 


FIG. 30. Cytoarchitectural map of human cortex, medial surface (after Brodmann). 
Reproduced by permission from O. S. Strong and A. Elwyn, Human Neuroanatomy, 
Williams & Wilkins, 1943, p. 360. 


Area 41 is the primary reception center for audition, and areas 21, 38, 
and 42 are related to the more complex processes of perceiving of words, 
language, and music. These areas are grouped together in the temporal 
portion of the brain and are joined in complex fashion by connecting 
nervous tracts. Testing the effects of destruction of area 41 is again not 
a simple matter since tests on animals involve learning or conditioning 
processes, and observations of residual hearing in humans following 
operative procedures are not definitive since the effects of the injury and 
the operations are not precisely limited. The early experimental work 


of Ferrier, Munk, Luciani, Schafer, and Hitzig and Golz demonstrated 
the fact that there was an area associated primarily with hearing. Their 
work was based on the behavior of lower animals following brain insult. 
The early clinical observations on humans by Dejerine and Von 
Monakow led them to somewhat similar conclusions although they did 
not agree upon the precise area. The work on the lower animals, while 
again not conclusive for humans, shows that there is fairly punctiform 
representation in the temporal cortex for auditory reception. Tunturi 
(249) using intact dogs and amplifying brain potentials found that the 
various auditory frequencies were primarily represented in the Sylvian 
gyri. Somewhat similar findings have been reported by Ades (250) 
(251) in his work with cats and monkeys. Hunter (252) using the 
auditory discrimination of rats, in a simple choice situation, found very 
little relationship between bilateral damage to the auditory area and 
loss of discrimination habit following destruction. Wiley (253), 
Pennington (254), and French (255) working on somewhat different 
problems do not support Hunter's contentions. Pennington worked on 
the post-operative retention of auditory localization habit in rats. In 
animals with lesions in the primary auditory area and in animals in which 
the damage was bilateral the results were not the same. Bilateral 
lesions were most disturbing, although there were some positive relations 
between disturbance of habit and extent of lesion when unilateral. 
French studied the discrimination of auditory rhythm in rats. The 
animals were trained to discriminate simple rhythms and then were 
operated upon. His measure of loss was the rate of relearning. He 
concluded that the task could be relearned after complete destruction of 
auditory cortex. Loss follows any cortical lesion but is not marked 
until about 70 per cent of the auditory cortex is destroyed bilaterally. 
Brogden (256), Rosenweig (257), Girden (258), Mettler, et al (259), 
and Kluver and Bucy (260) have used cats, dogs, and monkeys in at- 
tempting to trace out the functions of the various levels of the temporal 
lobe. The results of these experiments agree in a large measure with 
those of the preceding investigators. Any lesion of the cortex results 
in some loss of sensitivity for sound but bilateral lesions are more dis- 
astrous than unilateral lesions. Performances involving learning may be 
relatively intact since subcortical elements seem to function adequately 
for these purposes. In bilateral removal of the temporal lobes of 
monkeys it is found that they react to sounds but cannot use them for 
cues in behavior. The clinical observations on humans are extensive 
but the post-mortem examinations show that damage of rather large 


areas of the temporal lobes have been involved in most cases. In the 
immediate discussion, attention will be given only to the effects pro- 
duced on audition. Dandy (261), Gushing (262), and Gibbs (263) 
supply data on this point. Variations are reported from almost no 
effect to gross impairment. This seems to depend upon the bilaterality 
of the organic involvement. 


The parietal region of the brain contains the receptor representation 
for the dermal and somatic senses. If reference is made to figures 29 
and 30, the areas most directly involved are I, 2, 3, and 5. The methods 
of mapping the cortical areas include: (a) the recording of electrical 
potentials set up by peripheral stimulation and derived from the cortex; 
(b) degeneration of functional units; (c) ablation; (d) electrocoagulation, 
and (e) freezing. Some of these techniques are more applicable in 
determining intra- and inter-motor pathways than in aiding in the 
localization of sensory representation. Kennard (264) gives a very good 
summary of these techniques. The functions of the sensory cortex of 
the parietal lobe are exceedingly complicated and only a bare outline of 
the situation can be presented here. The various sensory elements 
from the skin and soma are grouped closely as they enter the vertical 
part of the lateral thalamic nucleus. They are then closely grouped in 
separate cell groups, probably in the dorsal lateral nucleus of the thal- 
amus. Lesions in this region may produce a loss of one or more of the 
sensations arising from the dermis or soma. Awareness of these sen- 
sations may take place at the thalamic level. In order to determine the 
effects of lesions in the sensory cortex, resort is usually made to complex 
tests of sensory capacity such as discrimination of qualities, distance, 
form, weight, etc. Such tests involve complex sensory synthesis as well 
as association and memory and hence include areas other than the sensory 
cortex. While the various anatomical parts of the body (toes, fingers, 
face, larynx, etc.) are well represented in fairly distinct areas in the 
motor cortex, anatomical representation is not nearly so well localized 
on the sensory parietal region. Those parts of the body that are most 
utilized as sensory organs seem to have the greatest cortical representa- 
tion and are the ones most affected by cortical lesions. For example, 
in limited lesions of the sensory cortex the sensitivity of the fingers is 
more likely to be involved than the proximal portions of the limbs. 
Parietal lesions produce sensory losses that are distributed anatomically 
over a single limb or body member and in addition a localized lesion is 


not likely to result in a total loss of primary sensations in any part of the 
body. Lesions involving the subcortical parietal region and capsular 
lesions usually affect many types of sensation and are frequently con- 
comitant with aphasia, apraxia, and plegia of varying degrees. These 
conditions arise through involvement of the motor cortex and associ- 
ation areas. Ruch (265) states that the sensory somatic areas overlap 
the motor areas to a limited extent. The overlapping is greater in the 
lower animals than in man. The following quotation from the above 
source will clarify the picture. Ruch says: 4 "The preponderant repre- 
sentation of sensory function behind the central fissure in man suggests 
a continuance of the migration of sensory function caudally on the 
cortex, without implying that the precentral gyrus has lost all sensory 
function. The condition obtaining on the human cortex may be con- 
sidered to be a hierarchy of somatic sensory areas, superimposed one 
behind the other, and subserving successively higher levels of sensory 
integration. The lowest member in this hierarchy is probably a primi- 
tive sensory motor area located in the precentral gyrus and the highest 
member is the supramarginal and angular gyri." Klebenoff (266), 
after reviewing the literature, comes to the conclusion that the alter- 
ations accruing with parietal pathology are of a psychophysical nature 
rather than of a more strictly psychological nature. There is still some 
question as to the representation of pain and taste in the parietal cortex. 
Bornstein (267) believes that the sense of taste is represented at the 
base of the parietal lobe. His observations are derived from clinical 
material. Ury and Oldeberg (268) contend that the pupillary reflex 
of cats with ablation of the parietal cortex did not respond differentially 
to painful electrical stimulation when the stimulation was inflicted on a 
leg neurally connected with an ablated area and when it was inflicted on 
a leg represented by an intact parietal cortex area. Discussion of some 
of the more complex functions associated with the parietal area will be 
carried out later. 


Areas 4 and 6 (see figures 29 and 30) are the motor areas and partici- 
pate in the operation of the effector system of the body. These have 
been discussed in part in Chapter III. We shall, however, relate 
damage in these areas more specifically to loss of motor function at this 
point. The best compendium dealing with these areas is that by Bucy, 
et al (269). The function of area 4 is chiefly motor and its function is the 

4 Ruch, T. C. Reprinted by permission of: Sensation: Its Mechanisms and Dis- 
turbance. Williams & Wilkins Co., 1935. 


integration of discrete voluntary movements. Representation of so- 
matic musculature follows a somewhat definite pattern. The lower 
extremities, toes, foot, and legs, are represented near the top of the 
fissure of Rolando, while the head and face musculature is represented 
near the bottom of this fissure (figure 28). There are more points in 
area 4 that produce movement of fingers than produce movement of 
wrist, and more points that produce movement of hands than feet. A 
small portion of area 4 acts as a suppressor or inhibitor and governs in 
part the relaxation of peripheral muscular contraction. Focal epilepsy 
is often encountered with small lesions in area 4. Flaccid paralysis is 
an accompaniment of destruction but is usually transient. Complete 
destruction of an area representing a limb is followed by loss of voluntary 
movement which is not regained. 

Area 6 possesses sensorimotor characteristics. Its subcortical con- 
nections are in the main extra pyramidal. This area functions bilater- 
ally to a much greater extent than area 4. The outstanding sign of dis- 
turbance in this area is reflex grasping. Reflex grasping is normal in 
infants, disappearing within about 6 months, and is reinstated with 
pathology of area 6. With bilateral lesions, apraxia, perse veration, 
apathy and hypomotility are found. In contrast with flaccidity, spas- 
ticity is usually present in lesions of this area. 

The thalamus, basal ganglia, and the cerebellum exert influence on the 
functions of the motor cortex. There are pathways from the cerebral 
cortex to the cerebellar cortex and back to the prefrontal cortex by way 
of the thalamus. Aring and Fulton (270) and Fulton, Liddell, and 
Rioch (271) have demonstrated that tremors which originate with re- 
moval of the cerebellum disappear upon extirpation of areas 4 and 6 
and that tremors in decerebellated cats were stopped by decerebration. 
Extirpation of area 6 alone accentuates such tremors. Kennard holds 
that the present evidence shows that interaction of area 6 and the basal 
ganglia smooths out and coordinates voluntary motor performance. 
Reorganization of function in these areas seems dependent upon moti- 
vation, cortical organization within a hemisphere, and age. 


It is generally agreed that several parts of the cortical structure in- 
fluence the action of the autonomic system. Area 6 and to a somewhat 
lesser degree areas 4 and 8 are important in this relationship. The 
frontal and temporal areas are also interrelated but for the present our 
discussion will be restricted to those areas mentioned first. The auto- 
nomic functions that are influenced by lesion or damage in area 6 are. 


(a) activities in gastro-intestinal tract, (b) circulation, (c) sweat secre- 
tion, (d) pupillary change, (e) bladder functions, (f) pilomotor changes, 
(g) shivering, (h) respiration, and possibly (i) sleep. 


The frontal cortical areas, numbers 9, 10, n, 45, and 32 in figures 
29 and 30, are association areas and are connected with each other by 
association fibers and are joined with projection areas and probably the 
thalamus by projection fibers. In view of the complexity of these 
areas we will review some of the pertinent studies of both the lower 
animals and man. The early observations of Ferrier, Hitzig and Bianchi 
were followed later by the observations of Franz (272) on cats. He 
contended in opposition to the claims of Bianchi that the frontal lobes 
are normally used for forming simple sensory associations and that 
lesions in this region destroy recently formed habits. Relearning was 
possible, however, and older fixed habits were not affected. Jacobsen 
(273) in working with monkeys felt that learning of problem boxes was 
not affected by lesions and recently acquired habits were not lost. 
Franz and Lashley (274) later removed a considerable portion of the 
frontal lobes of rats and found that the retention of learned reactions 
was not interfered with. Cameron (275) felt that the maze learning of 
rats was somewhat inferior after frontal lobe loss if the complexity of 
the task was increased. Loucks (276) also arrives at a somewhat 
similar conclusion from his tests of frontal destruction in rats that were 
required to learn a delayed alternation pattern. Maier (277) attacked 
the problem of "reasoning" as well as "learning". He destroyed dif- 
ferent amounts of tissue in both hemispheres by thermocautery. He 
concluded that loss of "reasoning" was related to amount of tissue de- 
stroyed whereas "learning" was little affected unless more than 40 per 
cent of the tissue was destroyed. Jacobsen (278) in working with 
monkeys with bilateral frontal lesions tested visual-kinesthetic-motor 
behavior with a series of problem boxes. He concluded that frontal 
association areas are not necessary for the mediation of simple manipu- 
latory habits or of visual pattern discrimination. In later experiments 
with delayed response tests, he contends that extirpation of the parietal 
association areas does interfere with performance either in accuracy or 
in length of delay. Jacobsen (279) (280) (281) associated with either 
Haslerud, Elder, or Nissen worked out a series of problems designed to 
test specific functions of the frontal lobes in primates. The conclusions 
of these experiments were that deprivation of frontal association areas 
produces a succession of temporally discrete units rather than an inte- 


grated performance. It might also be added that complex performances 
such as are involved in double and triple platform tasks are disturbed by 
unilateral lesion of the frontal lobes. This is verified in part by the 
investigations of Jacobsen, et al, and Warden, Barrera and Gait (282). 
Morgan (283, 284, 285) and his co-workers Stellar, Yarosh, Wood and 
Epstein, returned to experimentation on rats to determine the brain 
area involved in symbolic functioning. Their results led them to the 
general conclusion that behavior involving symbolic processes is medi- 
ated by the frontal areas and destruction of these areas adversely inter- 
feres with such behavior. Following ablation of the orbital surface of 
area 13 of Brodmann in monkeys, Ruch and Shenkin (286) encountered 
hyperactivity of running and pacing of a stereotyped nature. The 
work on animals indicates fairly clearly that unilateral lesions of the 
frontal lobes do not result in great impairment of a variety of behavior 
patterns. Bilateral destruction interferes with behavior to a rather 
high degree. More complex behavior is disturbed to a greater extent 
than simpler behavior. Well-fixed behavior is disturbed to a lesser 
degree than more recently acquired behavior. All of these foregoing 
statements refer of course only to those types of behavior mediated by the 
frontal areas. 

The observations and studies on man tend to show a somewhat higher 
degree of specialization of function than is encountered in lower animals. 
The findings are largely taken from cases with accidental lesion, with 
tumor and surgical removal of the frontal lobes or parts of them for the 
treatment of mental disorder. The observations of Goldstein (287), 
Feuchtwanger (288), Poppelreuter (289), and Kleist (290) on World 
War I cases with frontal lobe injury are of outstanding value. Many 
cases that reach the neurologist in the ordinary course of events have 
both organic involvement as well as psychological involvement. Soldiers 
are presumably healthy and have no history of difficulty before injury. 
It may be assumed that disturbance of function is therefore the result 
of injury or lesion. While there is not complete agreement on the 
effects of lesions of the frontal lobe due to injury and tumors, there is 
sufficient evidence in common to justify certain conclusions. The left 
frontal lobe seems to be dominant over the right and bilateral injuries, 
cause more disturbance than unilateral injuries Dandy (291), Penfield 
and Evans (292), German and Fox (293), Stookey, Scarffand Teitelbaum 
(294). Most authors agree that there is some intellectual deterioration 
Donath (295), Foerster (296), Bolton (297), Grunthal (298), Pfeiflfer 
(299), Baruk (300), Holmes (301), Kennedy (302). Inability to sustain 
attention is a characteristic reported by Bolton (303), Poppelreuter 


(304), Goldstein (305), Williamson (306), and Frazer (307). Sachs 
(308), Goldstein (309), Grunthal (310) have emphasized loss of in- 
itiative and apathy. Recent memory becomes defective and abstract 
thinking as contrasted with concrete thinking is impaired. It is the 
latter of these changes that has been attacked principally by psycho- 
surgery techniques. The two operations most frequently employed 
in the past are leucotomy and lobotomy. The former consists of re- 
moving a series of small cores at different levels of the brain structure, 
while the latter consists essentially of transecting fibers connecting the 
thalamus and the prefrontal region. We shall not consider at this point 
the question of whether operations of this kind are desirable from a 
therapeutic standpoint, but shall consider only those factors related to 
frontal area functioning. Grinker (311) says that there is a reduction in 
anxiety, less introversion, less interest in personal well-being. There 
is a marked expression of emotional tone but the emotions are shallow 
and quickly pass. There is an elevation of the mood. The patient's 
behavior is somewhat childish, cheerful and unselfconscious. Hebb 
(312), and Hebb and Penfield (313) find little change in intellectual 
level after removal of the temporal lobe as measured by intelligence test 
scores, although there is impairment on the non-language tests. Porteus 
(314), Rylander (315), and Halstead (316) are of the opinion that the 
classical tests of intelligence do not yield differences between pre- and 
post-operative conditions. Other workers have attacked the problem 
from the point of view of determining the particular components of 
intellectual functioning that may be disturbed by frontal lobe injuries 
Weigl (317), Goldstein (318), Nadel (319), Rylander (320), Yacorzynski 
and Davis (321), and Halstead (322). 

Among the changes that occur with frontal lobectomies (excision of a 
lobe) are interference with perceptual processes, involving: a longer 
time for impression, stereotypy, and reduction in range of perception. 
Power of abstract thinking is reduced. 

Halstead's (323) study is perhaps the most elaborate and the results 
will be presented in more detail. By means of a factoral analysis method 
he concludes that biological intelligence is composed of four factors 
which he describes as follows: 5 

"i. A central integrative field factor C. This factor represents the organized ex- 
perience of the individual. It is the ground function of the 'familiar' in terms of which the 
psychologically 'new* is tested and incorporated. It is a region of coalescence of learning 

6 Halstead, W. C. Reprinted by permission from Brain and Intelligence, University 
of Chicago Press, 1947. 


and adaptive intelligence. Some of its parameters are probably reflected in measure- 
ments of psychometric intelligence which yield an intelligence quotient. 

2. A factor of abstraction A. This factor concerns a basic capacity to group to a 
criterion, as in the elaboration of categories, and involves the comprehension of essential 
similarities and differences. It is the fundamental growth principle of the ego. 

3. A power factor P. This factor reflects the undistorted power factor of the brain. 
It operates to counterbalance or regulate the affective forces and thus frees the growth 
principle of the ego for further ego differentiation. 

4. A directional factor D. This vector constitutes the medium through which the 
process factors, noted here, are exteriorized at any given moment. On the motor side it 
specifies the 'final common pathway', while on the sensory side it specifies the avenue or 
modality of experience." 

His test battery for the factors yield data which lead him to state in 
part that: 

"i. In comparison with other types of subjects, individuals with damage to the frontal 
lobes have high impairment-index scores. 

2. This relation holds whether the lesion is unilateral or bilateral and whether it is on 
the right side or on the left side of the brain. 

3. There is no relation between the degree of impairment and the extent of the lesion. 
The obtained correlations are not significantly different from zero. 

4. This is true for the brain as a whole, for the cortical area of the prefrontal lobes, and 
for cortical areas outside the frontal lobes. 

5. No evidence for a general principle of mass action is yielded by this study. On the 
other hand, the available data do not bear upon mass action in restricted cytoarchitectural 

6. Bilateral subcortical lesions of the frontal lobes, as in lobotomies, do not disturb the 
functions reflected by the impairment index. 

7. There is no quantitative evidence of hemispheral dominance yielded by this study.' 

While Halstead's conclusions are interesting from the point of view of 
approach and should be given careful consideration, further evidence 
should be adduced before accepting his conclusions without caution. 


The last major area to receive consideration is the parieto-temporal, 
which is designated by the numbers 39, 40, 41, 42, and 43, in figures 29 
and 30. These areas are primarily concerned with language, learned 
skills, meanings of acts and symbols. There are two sources which 
are recommended for more extensive reading in this field: (a) Goldstein: 
Language and Language Disturbances (324); and, (b) Neilsen: Agnosia, 
Apraxia, Aphasia (325). These portions of the brain are tied up 
inextricably with some of the materials presented in the following 
chapter. We shall attempt therefore to separate the material somewhat 
along the lines of reserving certain kinds of descriptive material for the 


succeeding chapter and incorporating that material related to brain 
damage and localization of function in this chapter. The evidence of 
brain damage as related to the psychological function described above 
is largely derived from clinical observations on humans, although work 
on animals has contributed its share to our understanding. The pioneer 
writings of Wernicke, Lichtheim, Liepmann, Head, and others estab- 
lished the bases upon which later investigations have proceeded. Neil- 
sen holds that there are n association areas in each hemisphere that are 
involved in some manner with memory and association. He lists the 
areas as follows: 6 

1 . Prefrontal lobes 

2. The frontal writing center (foot of the second frontal convolution) 

3. Broca's convolution 

4. Pars triangularis of the third frontal convolution (area 45 of 


5. Anterior end of the superior temporal convolution 

6. Wernicke's area (posterior third of the superior temporal con- 


7. Area 37 of Brodmann 

8. Angular gyms (area 39 of Brodmann) 

9. Area 18 of Brodmann 

10. Area 19 of Brodmann 

11. Convolutions of Gratiolet 

These areas of the brain are so complicated in function that it is 
almost impossible to discuss them separately in detail and we shall 
indicate briefly what the function of each is. Area 18 of Brodmann is 
concerned with visual recognition; area 19 with revisualization of images; 
area 45 with vocal music and playing of instruments; area 38 with 
auditory recognition and interpretation; areas 41 and 42 (Wernicke's 
area) with comprehension of spoken language; area 37 of Brodmann 
with selection of words and formulation of sentences; Broca's area or 
area 44 of Brodmann with memory for making the vocal movements for 
articulating words; the convolutions of Gratiolet with naming parts of 
the body and designating laterality. Disturbances growing out of lesions 
of each of these areas are given specific designations and will be dis- 
cussed in more detail in the chapter that follows. 

Let us conceive of the total process of understanding or intellectual 
functioning as following somewhat this scheme. A stimulus impinges 

6 Neilson. Reprinted by permission from Agnosia, Apraxia, Aphasia; Their Value in 
Cerebral Localization. Paul B. Hoeber, Inc., 1946. 


upon the appropriate sense organ and if the receptive or perceptual area 
is not intact, blindness or deafness for example will prevail. If this 
area is intact but the recognition area is destroyed, the stimulus will not 
be recognized. That is, the individual will see an object but will be 
unable to tell you what it means. Further, if the first and second 
of these areas are intact but a lesion occurs in the revisualization area, 
there is inability to remember relationships and sequences. The indi- 
vidual may recognize a street and houses on the street, but still will be 
unable to get home. The motor side of the picture is equally com- 
plicated, especially with respect to language. One must remember 
words presented either visually or auditorially if one wishes to speak. 
Some individuals can repeat words just heard but cannot initiate speech 
of their own volition. Others can think of the words or acts they wish 
to employ but are unable to recall the motor patterns required. Hence 
we have disorders of the types just mentioned growing out of lesions of 
association areas controlling these activities. 



It was indicated in the preceding chapter that some of the more 
descriptive material related to disorders of association and memory 
would be treated in this chapter. 

Morgan (326) approaches abnormalities of association somewhat 
along the lines laid down in the introductory textbooks on psy- 
chology. In our presentation, we will take up the conventional topics 
but will modify Morgan's classification slightly. We will deal with 
aphasias and amnesias in separate categories. The disorders to be 
discussed follow: 

1. Retardation of association 

2. Flight and incoherency of association 

3. Dearth and perseveration of association 

4. Blocking of association 

5. Aphasias 

6. Amnesias 


Retardation of association is nothing more than the slowing down of 
the associative processes; for example, the time elapsing between a 
stimulus word and a response word. In thinking, however, one word or 
idea serves as the stimulus for the next, so that we conventionally mean 
by retardation the time elapsing between two successive ideas or words 
employed. Retardation might include complete blocking, but for 
reasons that will be obvious we prefer to treat the latter as a separate 

Experiments on normal subjects have demonstrated that various 
factors influence the speed of association. The connecting of a finger 
response to the flash of a light or to the sound of a bell is one of the simplest 
associations established in the laboratory. This is the well-known 
reaction time experiment which has been discussed in part in an earlier 
chapter. When the individual has to make a choice in response, asso- 
ciative recall is retarded, i.e. the associative time is increased. Some- 
times the so-called free association method is employed in the labora- 




tory and it is this particular type of association that concerns us to a 
much greater extent, since it more nearly represents the situation in 
thinking. The subject is given a stimulus word or chooses one himself 
and continues to name the words that occur to him. The time between 
the successive words spoken is the normal free association time. It has 
been found that these times may be as much as eight or ten times as 
great as those in the simpler forms of association reaction mentioned 
above. If further restrictions are imposed on the subject by having him 
name words belonging to a specific topic such as gardening or by having 
him respond with only verbs or adjectives, it may be found that the 
association time may be further retarded. Practice, up to a certain 
point, in both the simple and more complex associations will, of course, 
tend to decrease the time involved in association. This brief discussion 
of association reaction time indicates that a wide variety of factors are 
at work in controlling such times. The physiological condition of the 
subject, the mental set of the subject, and certain aspects of learning are 
all important items. In many types of mental disorder retarded asso- 
ciative response is one of the frequent symptoms. It may be exhibited 
by manic-depressive (depressed stage), neurasthenic and involutional 
melancholia cases. Sedatives in large doses, exhaustion or extreme 
fatigue, strong emotion, old age, and even sluggish habits may be 
responsible for slowness in association reaction. 

Wells (327) tested schizophrenic and manic-depressive patients by 
the Kent-Rosanoff list. His results have confirmed those obtained 
through routine observation. Most of the patients displayed long 
association times. With an improvement in their condition, there was 
usually a decrease in the association time. It has been suggested that 

blems might be lengthened 
otion. Wells was unable to 
psychopathic patients. The 
ed reaction or prolonged asso- 
Hull and Lugoff (328), Cros- 
;i) have attempted to establish 
idicator of an emotional situa- 
ciations are found; in others, 

association might be expected 
, neither histological nor bio- 
ssue would enable anyone to 
ormal in the majority of cases. 



When an individual changes the nature of the content of the asso- 
ciated ideas frequently, he is described as having flight of ideas. This 
change from one sequence of ideas to another is usually quick, but some 
cases may manifest flight of ideas with relatively slow association time. 
The associated responses lead from one to the other without logical or 
critical control. Within a short sequence the associations are usually 
logical; in a longer sequence of associated responses the shift from topic 
to topic is frequent and incoherent. It should be pointed out that 
although the connections between the longer sequences may appear 
illogical, this may not be the case. The connections which seem to be 
lacking to us may be perfectly clear to the patient. 

Incoherency is not entirely dependent upon flight of ideas, since people 
may make many associations that are both retarded and incoherent. 
This is encountered in both the controlled and free association methods 
in which we find inappropriate and unrelated responses to discrete 
stimuli; meaningless responses; and a series of unrelated words or un- 
related topics. 

The chattering of some men and women, the behavior of some children 
who when in amusement parks think of riding on the roller coaster while 
still on the merry-go-round, and activities of people who must sponsor at 
least six different reform movements simultaneously may be forms of 
behavior indicative of flight of ideas. These activities, however, are 
usually classed as normal. Exaggerated flight of ideas is encountered 
in some manic-depressive (manic phase), in some paranoid, and in some 
organic psychoses. The feebleminded often exhibit such associations. 

The experimental data obtained from people with mental disorder 
do not throw much light on the flight of ideas (time aspect). On the 
contrary, there is considerable evidence on the incoherency (incoherent 
to the examiner) of associations. Kent and Rosanoff (332), and Wells 
(333) have found in schizophrenia and manic depressive psychoses that 
there is a decrease in the "commonality" of response. The subjects 
give many unusual associations. With the return of the subject to a 
more nearly normal condition, the associations gradually become less 
individual or unusual. Murphy (334) in working with similar groups of 
patients concluded that classification was impossible on a basis of the 
logical relation of association since the mental disorder does not greatly 
influence the speech habits which are firmly rooted. His efforts to 
determine whether certain types of psychotic patients reverted to 
infantile associations turned out negatively. 



The etiology of decreased association time that is manifested in flight 
of associations is rather obscure. Reduction in time, either in simple 
reactions or association reactions, is usually attributed to lessened 
synaptic resistance, lowered threshold of receptor sensitivity, or in- 
creased irritability of the nervous tissue. All three assumptions may 
be correct, but how are we to account for the changes in the nervous 
system? Tobacco, small doses of alcohol, and certain stimulants 
produce such effects on nervous tissue, and we do find concomitant 
changes in speed of association. Tobacco and alcohol do not act in the 
same way. It is highly probable that the tobacco increases neural 
irritability, whereas alcohol modifies inhibitory tendencies. Some 
theorists have argued that the individual who is capable of making a 
wide variety of associations is the one that will be able to associate 
quickest. If this is actually true, then association time depends upon 
ability to learn or rather upon the amount of learning that has taken 

The underlying sources of incoherent associations may be either 
psychological or organic. Lesions in paresis (syphilis of the cortex of 
the brain), multiple sclerosis (hardening of the nervous tissue) and 
deterioration from old age cause aberrations of association. Some 
paretics may show exaggerated flight of ideas and incoherency before 
treatment with fever therapy but after treatment exhibit relatively 
normal associations. If the initial cause were lesion alone, the destruc- 
tion of the spirochete should not remove the cause, since fever therapy 
does not repair the lesion. Senile people have more coherent associa- 
tions on some days than on others. This indicates that variable organic 
conditions are responsible. Similar disturbances of association are 
produced, at least in some people, by large quantities of alcohol. Why 
the associations should be incoherent at certain times and relatively 
coherent at other times is one of the questions that cannot be answered 
satisfactorily with our present knowledge. 

The psychological origin of the kind of association under consideration 
can be described, but this is not necessarily an explanation. Patients 
who are preoccupied with themselves and their feelings may be unable to 
break through their circular chain of thinking, consequently associations 
supplied to exteroceptive stimuli are likely to be those linked with their 
preoccupation. These associations may therefore appear to be irrele- 
vant but are actually closely allied to the patient's feelings. The 
feebleminded may be unable to give coherent association because either 
they are unable to understand the stimulus or they have not learned 
the expected association. 


If we examine again a typical list of words given in the course of free 
association by a normal person, it will be found that as the time is in- 
creased the number of words in a given unit of time is diminished; in 
addition many words appear over and over again. This repetition of 
words is called perseveration. What has been found in speech associa- 
tions will also be manifested in other forms of response. For example, 
one of the authors witnessed a man who exhibited behavior typical of 
perseveration as he tried to start an automobile. After turning on the 
ignition, he stepped on the starter but the engine did not respond. 
He turned the ignition off and on again, and repeated his efforts to start 
the motor by stepping on the starter. Failure still resulted. He then 
raised the hood, looked at the motor and stepped on the starter, but still 
no explosions took place in the motor. Repetition of similar activities 
exhausted his battery. No real steps were taken to discover the cause 
of motor failure and after each casual inspection the same response was 
forthcoming. Sometimes perseveration is manifested by recurring 
tunes or the tendency to stick at a piece of work. Such behavior is 
also encountered in animal learning. Rats will enter a particular blind 
alley, long after the other blind alleys have been eliminated. The 
examples of perseveration cited are normal associative responses, but 
it is evident that the term perseveration must be defined in a number 
of different ways if it encompasses these diverse activities. Partial 
surveys of the literature on the topic are given by Dorcus (335), Hunt 
(336), and Ryans (337), and the reader is referred to these sources for 
additional usages of the term. 

Dearth of associations and perseveration of associations are charac- 
teristic of certain types of mental disorder. Amentia (feebleminded- 
ness) is a possible cause of both types of difficulty. Rethlingshafer 
(338) has compared normal and feebleminded children with college 
students in their tendency to resume interrupted acivities. She found 
that there was little difference between the groups studied. This 
study was not primarily concerned with language associations; hence 
it would not rule out the situation in which the person has not acquired 
an extensive vocabulary and is unable to use correctly the vocabulary 
that he has acquired. Beck (339) and Pfister (340) by means of the 
Rorschach Test confirm earlier observations that perseveration is very 
common among the feebleminded. Perseveration in these cases seems 
dependent upon failure to perceive relations rather than upon blocking; 
of associations. Patients with dementia (deterioration) caused by 


old age and neural destruction might be expected to show similar 
difficulties in associative response, since the aged forget their vocabu- 
laries through disuse and since neural lesions interfere with normal 
associations. Mental patients of some other types exhibit stereotypy 
to a great extent. These groups of patients are referred to the classes 
of dementia praecox (schizophrenia), compulsion neuroses, and anxiety 
neuroses. Their repetitions and stereotypes may consist of motor 
activities or fixed ideas of compulsion and obsession. The catatonic 
schizophrenic may maintain fixed postural positions for long periods 
of time or may repeat phrases over and over; the compulsion neurosis 
patient may have a compulsion of stamping his foot in a particular 
fashion while walking; and the obsessional case may have a recurring 
fear of contamination. Two interesting forms of perseverational 
motor responses are catalepsy and cerea flexibilitas. The first is 
encountered in hysteria, epilepsy and hypnosis; the second in schizophre- 
nia. There is no doubt that both involve disturbance of the associative 
processes. In catalepsy, there is a strong contraction of antagonistic 
muscles so that the body becomes rigid and will strongly resist bending. 
In cerea flexibilitas, the subject's body and members remain in any 
position in which they are placed. The tonicity is no greater, however, 
than in normal maintenance of bodily positions. Disturbances of 
association in these two disorders are taken into account in the clinical 
examination and are used in part as a means of classifying the disorders. 

Various investigators have endeavored to find out if the clinical ob- 
servations of perseveration are accurate and if they may be used for 
classification purposes without additional criteria. 

Test batteries for measuring perseveration have included: rate of light 
adaptation, rate of fusion of two colors, limen for sound after a loud 
noise, persistence of habits established while making strokes slanting 
in one direction when strokes are made in the opposite direction, ex- 
tended arm endurance, swaying with suggestion, inhibition of speed 
of line drawing or writing, strength of the psychogalvanic response, and 
rate of extinction of the psychogalvanic response. 

Wiersma, according to Bernstein (341) found that melancholic patients 
were stronger and that manic patients were weaker in perseveration 
when compared with normal subjects. Pinard (342) also supports this 
theory. Jones (343) disagrees with their conclusions with regard to 
manic patients. Mays (344) in seeking an explanation for persever- 
ational activities thought that they might be controlled by the auto- 
nomic nervous system. He reasoned that, if such were the case, the 


psychogalvanic response may continue for a much longer time in 
catatonic dementia praecox patients who are known to have a tendency 
toward perseveration, than in normal subjects. Shipley (345) extended 
this work to include the rate of extinction of the response; in addition 
he used as subjects, manic-depressives and psychoneurotics. Both 
authors found a high degree of perseveration as measured by their 

Cattell (346) summarizes the causal factors in perseveration as fol- 

i Perseveration of response through the referring of different ideas and stimuli to a 
single major sentiment or complex (delusions, melancholia, consistency of character). 
2. Perseveration due simply to mental asthenia and lack of spontaneity which permits 
any process of thought or action once started (by external stimulation) to proceed unus- 
ually long without interruption. 3. Perseveration due to the very nature of the nervous 
tissue and analogous to the inertia of the physicist, i.e., something which shows itself 
as a lag in all nervous processes, resulting in some interference of all consecutive mental 
activities. 4. Perseveration as an obstinacy of old habits in the face of habits being 
newly formed, or vice versa. 5. Quite apart from these varieties of what might be called 
true perseveration one meets instances, such as the mental defective's useless repetition 
of old and inappropriate responses in new situations, . . . 

Studies employing the Rorschach technique (associations to standard 
ink blots) and the Thematic Apperceptive method (story writing about 
a standard situation) tend to bring out the characteristics of association 
that are observed in the different types of mental disorders. These 
methods have been used to confirm uncertain clinical diagnosis. Klopfer 
and Kelley (347) present the methodology and summarize much of 
the work that has been done with Rorschach technique. Murray (348) 
and his co-workers have been instrumental in the development of the 
thematic approach and its application. A recent study by Wittson 
et al. (349) shows fairly clearly that the group form of the Rorschach 
is inadequate for distinguishing groups of normals from abnormals. 
By the suggested criteria forty-four per cent of normal recruits would 
have been classified as neuropsychiatric and forty-one per cent of 
definitely known neuropsychiatric cases would have been classified 
as normal. It appears, then, that the Rorschach method is useful only 
as an adjunct to clinical diagnosis. 

Most of the experiments with disordered people do not furnish any 
answer to the question of etiology of the association disturbance. 
Forbes (350), and Forbes and DuBois (351) have investigated cerea 
flexibilitas and catalepsy. They found that during sleep the cerea 
flexibilitas disappeared and that the cataleptic's motility approached 


that of the normal sleeper. The experiments show that integrative or 
associative factors are primarily responsible rather than some organic 
factor. The work with insulin shock, metrozol and benzedrine sulphate 
demonstrates that some cases of dementia praecox with their persever- 
ational tendencies can be improved. Whether improvement in asso- 
ciation under these treatments is due to a change in neural tissue condi- 
tion or whether the shock breaks through the circular and repetitive 
association that is taking place in the patient will have to be decided 
in view of further work. More will be said of these forms of treatment 
of mental disorder in a later chapter. 


Blocking of association is the inability to make any form of motor 
response. This comprehensive definition must be accepted even though 
only verbal response is usually implied. The blocking may be complete 
or partial; it may hold for only one response or a number of responses 
involving a single topic; and it may have certain features related to the 
time factors of memory. For our purposes, blocking can be discussed 
best under the topical headings of aphasia and amnesia. 


The associative processes are dependent to a certain extent upon the 
neural structure and the coordination of the various parts of the brain. 
This is clearly established in the chapter on brain damage. Aphasia 
is a partial or complete loss of voluntary ability to express ideas by 
speech or writing. This inability of speech may be produced by lesions 
either of the sensory areas, the association fibers, or the motor areas. 
If speech is lacking because of a lesion in a motor area, it is referred to as 
motor aphasia; if the lesion is on the sensory side, the loss is called 
sensory aphasia; and if the lesion is of the commissural fibers, it is 
designated conduction aphasia. The motor and sensory aphasias may 
be restricted still further by specifying the locus of the lesion; thus we 
may have cortical, transcortical and subcortical aphasias. 

Other writers have attempted to localize speech and communication 
dysfunction in a more discrete fashion. They believe that a lesion in a 
specific portion of the brain such as the first temporal convolution 
(Wernicke's area) would destroy sound images which are necessary for 
understanding words or speech (sensory aphasia), or that a lesion of the 
third frontal convolution of the left hemisphere (Broca's area) would 
result in the inability to produce voluntary speech (motor aphasia). 

A slightly different method of classifying the disorders related to 


communication (speech, gesture, and writing) is on a basis of symp- 
tomatology. Individuals may be unable to speak, to write, or to make 
gestures for any one of a number of reasons. If the patient is unable to 
understand certain spoken words or certain sounds or cannot understand 
certain written or printed words, he is suffering from sensory aphasia, 
but more specifically he has word blindness or word deafness. Some 
neurologists prefer to use the terms optical alexia and acoustical alexia 
respectively for the preceding terms. Inability to recognize objects by 
touch is called tactile aphasia (sensory type) and has been ascribed to 
lesions in the central parietal lobe. In the case of acoustical alexia it 
has been assumed that the area for the retention of auditory images has 
been affected in some manner so that the image for calling into use the 
correct sound in voluntary speech is not available. A similar mecha- 
nism is involved, theoretically, in word blindness. The brain area for 
the retention of visual images is affected. The scope of localized areas 
may now be extended to include areas for all varieties of sensations and 

Many of the performances of aphasic patients indicate that they may 
understand what is said to them, but the proper associations for speaking 
are lacking. The individual may be unable to tell the name of an object 
placed before him, but he can write the name of it or point to it when it 
is placed before him in a group of objects. The inability to speak or 
write or to perform specific parts of these functions has given use to 
such terms as amimia, apraxia, anarthria, and agraphia. These terms 
have been defined in different ways by different authors, but for our 
purpose the following definitions will serve. Amimia is the inability to 
imitate or to make gestures. Apraxia is the inability to execute move- 
ments of indirect purpose. It includes those movements which are 
concerned with communication as well as other movements of the hands. 
The subject has difficulty with kinesthetic images or is lacking in ki- 
nesthetic memory. Anarthria is the inability to execute articulate 
speech. Agraphia is the inability to write. Amusia is the inability to 
understand or reproduce musical sounds. If the loss consists of the 
inability to comprehend musical sounds, it is called sensory amusia; 
if the music is understood but the power of singing or reproducing 
music is lost, it is referred to as motor amusia. Gerstmann (352) 
feels that there is a well defined syndrome which includes finger 
agnosia, agraphia, and acalculia (disability of calculation). While 
these usually are grouped together, it is possible that they may occur 
singly. This syndrome results from a lesion in the parieto-occipital 


region of the brain (specifically in the angular gyrus in its transition to 
the second occipital convolution). The patient cannot orient himself 
with reference to the individual fingers of either hand; he cannot differ- 
entiate between his fingers; he cannot name them; and he cannot imitate 
finger postures of the examiner. Very often a patient cannot recognize 
laterality of his own body; he is unable to write and he may be unable 
to perform simple arithmetical calculations. Gerstmann ties these 
complex functions together on the basis that in the development of 
writing and calculating the fingers play an important role. 

The variety of conditions that may be encountered can be ascer- 
tained by referring to Neilsen's (353) appendix in his treatise on "Ag- 
nosia, Apraxia, Aphasia". He lists 24 different varieties of agnosia; 
ii varieties of agraphia; 12 varieties of alexia; I variety of amimia; I 
variety of amnesia; 16 varieties of aphasia; 6 varieties of apraxia; I 
variety of autopagnosia; and 15 varieties of irreminiscence. He defines 
the major categories somewhat in accordance with the definitions pre- 
sented above. We will however redefine the categories in his ter- 

Agnosia is a loss of function of recognition resulting from an organic 
cerebral lesion involving one sense organ only. 

Agraphia is a descriptive term and when not qualified means loss of 
ability to write. 

Alexia is a descriptive term meaning the inability to read, without 
reference to the physiologic cause except that it is due to focal cerebral 

Amimia is a purely descriptive term used to designate loss of ability to 
mimic gestures. 

Amusia is a descriptive term meaning a disturbance of the musical 

Aphonia is defined as "loss of language association with." 

Apraxia is loss of ability to perform as desired or as requested, through 
loss of memory of how to perform. 

Autopagnosia is loss of ability to recognize parts of the body. 

Irreminiscence is a term coined to designate a disturbance of ability to 

Neilsen's classification system represents an extreme organic and 
specific point of view with regard to aphasia and allied disorders. In 
contrast to this point of view, the work of Marie (354) and Head (355) 
and Goldstein (356) on aphasia differs sharply. Marie was among 
the first to question the idea that speech was composed of a number of 


separate processes, such as the primary sensation of audition, the 
primary sensation of vision, the primary sensation of the tactile sense, 
corresponding sensory and motor images and the motor component 
itself. He viewed speech as a complex process which involved the 
whole cortex in contrast with the view that small isolated parts (mosaics) 
served for each of the above processes. He argued that any central 
lesion would produce some major symptoms, but in addition there 
would be a general lowering of efficiency which he translated into a 
lowering of intellectual ability or thinking. The outstanding symptoms 
of the patients suffering from aphasia may correspond roughly to the 
locus of the lesion, but there are, however, effects produced which have 
a much wider influence in the total functioning of the nervous system. 
Head holds a similar view. Disorders of communication or language 
cannot be referred to lesion of special brain centers, since speaking, 
writing and gestures are not distinct psychic functions and do not have 
specific areas any more than do a large number of other motor activities 
that require the integration of the sensations arising from the special 
senses. Since speech is a very complex process in its development, it 
must be assumed that the total functioning of the cortex and other 
related tissue must be involved, even though no disturbance is noted. 
Head insists that there is probably no clear-cut case which exhibits a 
dysfunction of only an isolated aspect of speech; he further states that 
the severity of the lesion will, to a considerable degree, determine the 
amount or degree of dysfunction rather than the nature or kind of 
dysfunction. He differentiates aphasias on a basis of the outstanding 
defective characteristics of the use of words. These symptoms of 
aphasia may be referred to as disturbances of understanding symbols 
and attaching meaning to them. 


We mentioned acoustical and optical alexia in our previous discussion. 
These forms of aphasia have been suspected of playing a major role in 
reading disability (dyslexia), and we will present a discussion of the 
problem at this time because it fits in rather closely with both the pre- 
ceding and subsequent material, 

Reading is a process as complex as speech and writing, and disorders 
may be manifested in the total process predominantly because of mal- 
function in one part or another of the process. Reading involves the 
visual mechanism, possibly the auditory mechanism, the kinesthetic 
mechanism, the central mechanism and various parts of the motor 


mechanism. The proper integration of the different sensory impulses 
coupled with adequate motivation leads to the development of normal 
reading habits. Unfortunately individuals are encountered who do not 
develop or who have lost the normal ability to read. Such people are 
said to have dyslexia. Some people with a specific form of dyslexia 
(sensory alexia) are unable to recognize printed or written words; others 
can recognize printed or written words but are unable to comprehend 
their meaning; still others may recognize and comprehend the meaning 
of words but are unable to read aloud what is written or printed. This 
latter form is called motor alexia. 

All of the above disorders may be either congenital or acquired. That 
is the individual may never have developed the ability to read, or he 
may have completely mastered the art of reading but due to lesion or 
other causes may have lost it. 

In addition to the general dysfunctions which are identified with 
recognition, comprehending and reproduction, there are a number of 
specific alexias that are more difficult to fit into the picture. These 
involve the inability to read music, mathematical formulae, and foreign 
languages when reading ability is otherwise normal. 

If the dyslexias are not viewed as "all or none functions," then we 
might anticipate only a partial loss or a weakening of the various func- 
tions which would result in a graded series of dysfunction. This seems 
to be the case, since many individuals read slowly and have poor com- 
prehension. These same people, if given adequate time, can demonstrate 
that they comprehend material that is seen, as well as faster readers. 
The rate of reading may influence comprehension; on the contrary, the 
rate of reading may be determined by the ability to comprehend what is 

The problem of reading disability involves the whole field of memory, 
association and learning, but our discussion will be confined only to those 
factors that play a major role. 

The most obvious cause of reading disability of the congenital type 
is mental deficiency. Neural development must proceed to a stage that 
will allow the organism to function normally, otherwise the complex 
patterns involved in reading cannot be established. The specific 
factors that cause mental deficiency are numerous, and we need not 
determine the exact degree of enfeeblement that will interfere with 
reading. Mental deficiency is not the cause of many cases of dyslexia, 
since standardized performance tests have shown that the scores of 
many nonreaders are quite comparable to those of normal readers. 


Cases of acquired dyslexia may be accompanied by mental deterioration, 
but in some cases at least, the deterioration of other mental functions 
is not coexistent with dyslexia. 

Visual disorders have been suspected as a contributory cause. Writers 
have argued that since the visual stimuli do not arouse adequate or 
appropriate sensations, comprehension of these stimuli must be interfered 
with. Almost all visual functions have been investigated. Gray (357), 
Monroe (358), Eames (359), Selzer (360), Fendrick (361), Stromberg 
(362, 363) and others have been interested in visual defects. Gray and 
Fendrick have found that the visual acuity of poor readers is inferior 
to that of good readers, although in many poor readers, inferiority of 
visual acuity is not found. Monroe also suggests that visual acuity may 
be a contributory factor. Stromberg states that fast and slow readers 
cannot be distinguished on a basis of peripheral sensory tests. Eames 
and Selzer find muscular imbalance of the eyes in poor readers which 
may result in noncorresponding images, thus producing a blurred or 
indistinct object or form. It is possible that exophoria and esophoria 
may influence reading ability in some particular cases. In our discus- 
sion of strabismus, we pointed out the fact that the function of corre- 
sponding and noncorresponding points is in part a learned function. 
If the noncorrespondence has existed from birth, it may not cause any 
appreciable error in perceiving form. Furthermore, some cases of 
reading disability do not have muscular imbalance. Erratic eye 
movements during reading have been suggested as a possible cause. 
Numerous records of the eye movements of fast readers, slow readers 
and nonreaders have been made. The proponents of this notion have 
found that the nonreader's eye movements are unlike those of normal 
readers. The movements differ in a number of respects. While such 
difference in movement may account for differences in speed of reading, 
they do not afford a basis for explaining the acquisition or lack of acquisi- 
tion of reading ability. These eye movements are more likely the result 
of reading habits than the cause. Fernald (364) has reported cases of 
total reading disability in which the eye movements have been abnormal 
after reading ability has been established at a normal level. The writer 
has seen a case of continuous nystagmus that showed no dyslexia, yet 
the eye movements would certainly not conform to those of normal 
readers. One important point must be remembered in connection with 
studies of eye movements of nonreaders. Even though individuals are 
presumably attempting to read, they would not be expected to have 
eye movements comparable to eye movements during reading since they 
are not actually reading. 


The auditory and speech mechanisms play a part in the reading proc- 
ess, therefore, disorders of audition and speech have been postulated in 
the etiology of reading disorders. Monroe (365), Gates (366), and 
others have contended that poor hearing is a handicap in reading. Bond 

(367) has found that this is true only if the students are taught by the 
phonetic method rather than by the look-and-say method. Kennedy 

(368) has shown that a loss in the frequency range above 2048 d. v. 
is of greater importance for good articulation than losses below this 
level. If these contentions are reliable, then the difficulty is not a 
reading dyslexia but one of audition. 

We find that reading disability frequently is accompanied by speech 
disorders of various kinds. While inability to form the necessary speech 
movements for reading orally may interfere with the acquisition of 
normal reading habits, it appears that the speech disability is just 
another symptom of a more general malfunctioning of the association 
processes. Bond (369), for example, found that the incidence of speech 
defects was approximately the same for good and poor readers, although 
there was some difference depending upon whether oral or silent reading 
was used as the criterion. Theories of eye, hand and cerebral dominance 
have followed from the theories of stammering and stuttering. The 
results of testing these theories of reading disability have not been 
especially fruitful. Some reading disorders are associated with domi- 
nance or lack of dominance of a specific function, but the rate of inci- 
dence is no higher in groups with poor reading ability than in control 
groups. Fernald (370) has summarized the theories on dominance and 
has critically evaluated the work of Orton, Monroe, Dearborn and 
Gates. She also furnishes evidence from her own cases that tends to 
disprove the cerebral dominance theory. 

The dyslexias (true alexias) are those in which there is total inability 
to perceive letters or words, and the disorders may exist without other 
language or agnosic complications. These alexias may be caused by a 
lesion of the first temporal convolution, or of the angular and supra- 
marginal convolutions. If the theories of mass action could be extended 
sufficiently, cases of alexia due to specific lesion should be able to re- 
cover reading ability through adequate training. If, on the contrary, 
specificity of function holds for humans, no amount of retraining would 
overcome the difficulty. Fernald (371) reports that Sullivan has had 
success in retraining two organic cases of alexia. 

Cases in which the individual is unable to learn to read but in whom 
there is no known lesion are more numerous than the organic cases 
encountered in medical practice. The inability to explain why certain 


people are unable to acquire reading habits leads to the belief that is 
founded on clinical material, that a particular portion of the brain 
corresponding to the areas in which lesion had been observed was mal- 
developed. If maldevelopment is the causal factor, then the disability 
for understanding certain kinds of printed or written symbols should be 
no greater than for other kinds. Specific disabilities of this kind are 
encountered, and since most of these congenital cases can be taught to 
read, we must view with a certain amount of skepticism the maldevelop- 
ment theory. How many of these cases are due to emotional blocking, 
improper motivation, inadequate techniques in instruction, and sug- 
gestion is difficult to estimate. In the clinic at the University of 
California at Los Angeles cases that may be attributed to each of the 
above causes are encountered. Fernald attributes many of the cases 
of word blindness to the techniques used in the educational system in 
teaching reading. She says, "it seems that most cases of reading dis- 
ability are due to the blocking of the learning process by the use of 
limited, uniform methods of teaching. These methods, although they 
have been used successfully with the majority of children, make it 
impossible for certain children to learn because they interfere with the 
functioning of certain abilities which these children possess. At present 
one of the main blocks is the use of the extremely visual method of 
presentation with suppression of such motor adjustments as lip, throat 
and hand movements." Fernald (372) has amplified her theories and 
has presented an excellent discussion of remedial methods in her volume 
on Remedial Techniques in Basic School Subjects. 

Almost all of the people who attempt to correct alexia or word blind- 
ness proceed on the general theory that reinforcement of the visual 
stimuli with either auditory or kinesthetic stimuli will somehow establish 
the visual-speech relationship which has never properly functioned in 
the absence of these reinforcing stimuli. While the technique seems to 
work, our understanding of its operation is almost nil. Explanation 
necessitates postulation of mass action, vicarious functioning of neural 
centers, summation of stimuli which intensify the effects on the visual 
speech centers and other vague concepts. 

If the case is one in which emotional maladjustment toward the 
reading problem has arisen because of some other failure in adjustment, 
improvement in reading ability will take place with better social adjust- 

Inadequate motivation has been suggested as a possible cause. 
Youngsters frequently do not understand the necessity for acquiring 


reading ability, and unless the disability seriously handicaps them in 
their interests, they may be unwilling to expend the necessary energy to 
learn. A negative attitude develops, and the youngster no longer 
attends to printed material. This explanation is similar to Hurst's 
inattention theory for explaining functional sensory losses. We have 
presented in brief survey the material related to dyslexia. While much 
material on the general subject of reading has been omitted, our survey 
should orient the student to some of the problems. 


We have discussed certain disorders that occur in linking our percep- 
tions together. This linking of perceptions must make use of imagina- 
tion and memory. Some psychologists distinguish between these 
various concepts only in a perfunctory way. We have described the 
connecting of perceptions and ideas as association; others call this 
learning. The one factor that differentiates memory and imagination 
from certain phases of association is time. Human experiences consist 
largely of perceptions, and when these are reproduced in the form of ideas 
or images, memory is involved. We say, therefore, that memory in- 
cludes only those aspects of mental life that have previously been per- 
ceived. In other words, memory is personal and the temporal reference 
is always to the past. 

Memory, for convenience of discussion, can be broken down into four 
phases: I. Impression, which depends upon stimulation and resulting 
sensation. Whether the impression needs to be liminal to give rise to 
memory is an important question that need not be answered at this 
point. 2. Retention, which depends upon neurological condition. 
3. Recall, which involves re-excitation of the neural pathways that 
have been modified by previous impression. 4. Recognition, which 
signifies identification of previous perceptions and which sets off true 
memory from imagination. These phases of memory are, of course 
not separate and distinct events that can be set apart introspectively. 
Memory, on the contrary, is one continuous process. This must be 
kept in mind during our discussion of memory disorders, but there are 
certain disorders of memory that can be attributed to one phase rather 
than another. 

Theoretical objections may be raised against the usage of the term 
memory as outlined, since some conditioning experiments show that 
learning takes place when only the motor cells in the ventral horn of the 
spinal column and the motor end plates are stimulated. It is also true 



that many habitual responses occur in which memory originally played 
an important part but is no longer of any significance. An attempt to 
relate learning of these types to a theory of memory would carry us too 
far afield. 

The three major categories of memory disorder are amnesia, param- 
nesia, and hypermnesia. Amnesia is loss of memory, yet it may be 
questioned whether one can have a total loss of memory and still be 
conscious. A partial loss of memory is really implied when the term 
amnesia is employed. Either a period of time is blocked out or certain 
events cannot be recalled. 

Amnesia may have as its basis any one of the first three phases of 
the process. Whether a stimulus is in focal or marginal attention deter- 
mines to a considerable degree whether it will be remembered at a later 
date. We are constantly reacting to numerous stimuli that we cannot 
later recall. We may answer a question that someone asks while we are 
busily engaged in writing and be unable to remember either the answer 
or question a short time later. Stimuli occurring while under the in- 
fluence of drugs or an anesthetic, while in the throes of a high fever, and 
while extremely fatigued, may invoke activities or responses. Girden 
(373) found that conditioned responses could be established in curarized 
monkeys but that such learning or conditioning is completely repressed 
upon recovery from the drug state. Memory for such stimuli is very 
likely to be poor and is ascribed to weak impression. Either the in- 
tensity of the stimulus is not strong enough to bring it in focal attention, 
or the condition of the nervous system is such that the resulting neural 
activity is somehow modified. Emotional states and injury may pre- 
vent adequate impressions, although such states usually interfere also 
with recall. 

If the amnesia has a forward time reference, that is, extends to events 
just after an injury or emotional shock, it is called anterograde amnesia, 
and the tendency is to explain the loss by improper or inadequate im- 
pression. Of the two cases immediately following, the first is a typical 
case of anterograde amnesia; the second may be considered a partial case 
of amnesia due to poor impression. 

I. A man about 40 years old was involved in an automobile acci- 
dent in which he killed a pedestrian. He professed memory of seeing 
the man standing by the edge of the road, of seeing another car, and of 
his own actions controlling his car up to the moment of the impact; but 
he was unable to remember anything that transpired after that until the 
injured man was placed in an ambulance. The events occurring in the 


interim, striking the man, calling the ambulance, and talking with other 
people, were completely blocked out due to the emotional shock. It is 
highly improbable that memory for these events can be restored. An- 
terograde amnesia is in this respect in sharp contrast with retrograde 
amnesia which will be discussed presently. 

2. A business man consulted one of the authors. He complained 
that his business had slumped because he could not remember neces- 
sary data. In discussing his problem the conclusion reached was that 
his chief difficulty lay in the fact that he was not trying to remember. 
He had convinced himself that his memory was poor because he was 
unable to quote figures and dates as well as some other men. It hap- 
pened that his work required knowledge of the affairs of some five or six 
companies whereas the people with whom he was comparing himself 
had knowledge of one company. Their ability to remember figures 
without reference to notes was to be expected since they had fewer to 
deal with. On actual memory tests, the patient was slightly better 
than average. In this case, lack of attention based upon the belief 
that a poor memory was at fault operated against adequate impression. 

Neural deterioration and lack of neural development prevent proper 
impression. The feebleminded child or adult is unable to learn many 
things. His nervous system is undeveloped to such an extent that 
there is probably both weak impression and retention. The individual 
who has senile dementia or dementia from other causes may be able to 
remember remote events but cannot remember relatively recent events. 
Senile patients can recall events of their childhood, even though they 
may ask you the same question over and over again. This behavior 
points to disorder of impression rather than recall, since the childhood 
experiences that are recalled were fixed under more favorable neural 

Hunt (374) has summarized the work of Hull, Wechsler, Liljencrants, 
and Moore who have tried to separate the factors of impression and 
retention in the memory disorders of psychotic patients. Hull (375) 
found that dementia praecox patients and paretics learned much more 
slowly than normal people, but material once learned was retained as 
well by the patients as by the normal people. Wechsler (376), Lil- 
jencrants (377) and Moore (378) worked with patients having organic 
psychoses, including Korsakow's psychosis, paresis, cerebral arterio- 
sclerosis, and senile psychoses. While the evidence indicates that the 
various phases of memory all suffer to a certain extent, the greatest 
impairment is in impression. Krechevsky's (379) work on rats adds 


to the other evidence that supports the contention that improper im- 
pression caused in part by inattention is one of the major items in 
organic lesions. Rats with varying cerebral lesions were inferior to 
normal animals in learning a dark-going habit; but when electrical shock 
was administered to sustain attention, the differences in learning capacity 
of the two groups were sharply lessened. 

The second phase of the memory process was called retention. Re- 
tention itself is not directly observable but its results are seen in later 
performance of some act. Recall and recognition are dependent upon 
the amount of retention that exists. We have a fairly large fund of 
information concerning the factors that affect retention but practically 
no information concerning the neural correlates. We know that some 
time after efforts to learn are stopped, additional time is required to 
fixate the learning. That is, some psychological processes continue, 
which, if interrupted, tend to break down retention. We know, in 
addition, that interpolation of other materials to be learned before this 
fixing process has been completed also tends to inhibit retention. Cam- 
eron (380) places great emphasis on the "continuation process" in the 
memory of senile patients. He found that senile patients could retain 
numbers just heard for a few minutes provided no other activity was 
engaged in. They were unable to recall the digit if memorizing was 
followed by a minute during which they were asked to spell a list of 
words backward. Any strong emotional situation or any injury inter- 
fering with cerebral circulation or neural metabolism produces an effect 
which inhibits fixation. We know, further, that materials tend to be 
forgotten, i.e. are not retained, in a definite order. More recently 
learned materials are forgotten first. This is true within limits, since 
certain acts or responses tied up with strong affects may not conform 
to this rule. Similarly, the extent of the learning may influence the 
sequence of loss. 

Zubin and Barrera (381) taught mental patients paired word associa- 
tions before they were given electric shock therapy. They tested 
memory by recall, recognition, and relearning methods after the electric 
shock therapy had been administered. They found that while learning 
ability was not impaired, recall and recognition were affected adversely. 
The material learned immediately before the shocks was affected more 
than the material learned earlier. This form of disorganization pro- 
duces memory disturbances that are quite similar to those produced 
by other means. Duncan (382) demonstrated that well-established 
habit reversal patterns were destroyed by electric shock and that the 


animals reverted to earlier forms of behavior. He argues that amnesia 
for the more recently established habits is induced. Sharp, Winder and 
Stone (383) have indicated that in addition to memory, reasoning 
(the ability to bring together spontaneously two elements of past 
experience without having them previously associated by contiguity) 
is impaired by electric shock convulsions. In humans, Brody (384) 
has demonstrated that memory defects for familiar material, names, 
places, and habits of work may be permanent in some patients treated 
with electro-therapy. More information on this topic will be presented 
later in the text. Sherman et al. (385) conclude from their study that 
chemical or electrical convulsions produce no significant effect on imme- 
diate or recent memory. The authors of this book are inclined to 
believe that the bulk of the evidence supports the former investigations. 

We mentioned that some emotional situations and blows on the head 
may produce failure of memory. When this occurs, it is called amnesia. 
Under these circumstances, the length of the amnesia period is variable. 
It may extend for only a few minutes or it may extend to events cover- 
ing many years. The amnesia may be complete for all events or it may 
be rather selective depending somewhat upon the various learning 
factors that have been pointed out. 

In retrograde amnesia, the loss extends to events prior to the emo- 
tional shock or injury. Although the term retrograde amnesia may be 
applied to loss for any time period preceding a trauma or some episode, 
it should be restricted to a relatively brief period so that it can be dis- 
tinguished from the more generalized amnesias. Janet felt that this 
distinction was necessary for a clear understanding of the problem. 
Retrograde amnesia is one of the symptoms of hysteria but may be 
symptomatic of a concussion. When found in cases with hysteria, it 
is said to be functional in origin; when accompanying concussion, it is 
organic. Cerebral concussion from air blast may or may not be ac- 
companied by amnesia. Schwab (386) studied 350 such cases, of which 
only 40 per cent showed amnesia, but even cases having amnesia did 
not show retrograde symptoms. It was found that the reactions in 90 
per cent of the cases were anxiety reactions which yielded readily to 
psychotherapy. Rudolph (387) has shown further that retrograde 
amnesia may occur with or without loss of consciousness at the time 
of the trauma. In those cases in which unconsciousness occurs the 
derivation of the retrograde amnesia is not related to the post-traumatic 
unconsciousness. The amnesia may result from repression caused by 
fear. Koff (388) found that the Rorschach differentiates cerebral con- 


cussion from psychoneurosis fairly satisfactorily. Sixty-seven of 75 
cases were correctly diagnosed as having organic impairment when the 
protein level of the spinal fluid was used as the index of organic involve- 
ment. Further, in 89 out of 100 cases with low spinal fluid protein, the 
Rorschach picture was one of psychoneurosis. A case of retrograde 
amnesia due to concussion is cited in the following paragraph. 

A student at the university left the laboratory to do an errand several 
blocks away. En route, he stopped at a restaurant, bought a sandwich, 
and talked with several people. In crossing the street, he was struck 
by an automobile, became unconscious, and was removed to a hospital. 
He was unable to remember later where he was going, what he had done 
after leaving the university, or with whom he had talked. 

Theoretically, amnesia due to concussion represents failure of re- 
tention. The disturbed circulation prevents retention. If such is 
actually true, then memory for the lost events cannot be reinstated. 
Syz (389) has demonstrated, however, that amnesic events due to or- 
ganic disturbance can be reinstated sometimes. The seventy of the 
organic disturbance is a determining factor. Shipley and Kant (390) 
in their review of treatments, including metrazol, for schizophrenia 
refer to reports of amnesia by various people. Retrograde amnesia 
is encountered for both the injection of the metrazol and preceding 
events. Difficulty is encountered in naming objects and parts of the 
body. After the convulsion, induced by the drug, functions return 
somewhat in the following order: esthesia, prosexia, gnosia, praxia, 
and mnesia. Reinstatement of functional losses is fairly easily accom- 
plished under hypnosis, by association techniques, or during automatic 

Since synthesis of memory is possible in some cases conventionally 
designated as retrograde amnesia, it is probable that the phase of the 
memory process involved is not retention but recall or possibly recogni- 
tion. This raises the old question that has received much attention in 
the literature as to whether anything once in memory is ever completely 
lost. This argument originated because under experimental conditions, 
materials apparently forgotten are relearned in less time than was 
required for the original learning. 

Systematic and general amnesias are encountered in hysteria, fugues, 
multiple personality and hypnosis. In these disorders the amnesia 
may be complete for the entire past life, for a short period of time, for 
a particular person, for a given episode, or for some simple performance. 
These amnesias cannot be attributed to those phases of memory which 


have been termed impression and retention, but to recall. In the ma- 
jority of cases, recall is established spontaneously, with suggestion, or 
through associations. Definite relearning is not required. The causes 
of the amnesias in the mental disorders mentioned before, as well as 
their treatment, are brought out in later chapters. 

The last phase of memory (recognition) is identified with a group of 
disorders that are called paramnesias. Recognition differs from recall 
in that identification of the object or thing remembered, occurs. If one 
is given a list of words, nonsense syllables or figures to memorize, and 
is asked to write down as many as possible after five repetitions, he is 
said to have recalled them. If the number of items is sufficiently great, 
there will be many that cannot be recalled. If, however, the subject 
is shown a list containing some of the words or numbers that he could 
not recall and some others that he had never seen before, he will be able 
to pick out from the list most of those to which he was originally ex- 
posed. This identification of materials that could not be spontaneously 
recalled is said to be recognition. Throughout life we are constantly 
recognizing things that have not been spontaneously recalled, and we 
are recalling things that are misidentified. Most people have had the 
experience of remembering a person's face and associating another name 
with it. This form of perversion of memory takes place almost daily. 

The various forms of mistakes in recognition can be grouped with 
respect to (a) time; (b) place; and (c) persons or things. Time errors 
in recognition may involve simple disorientation of day, week or year. 
There may be a more generalized shifting of time in relation to the 
happening of a series of events similar to that which occurs in retro- 
anterograde amnesia. Under these circumstances, recent events are 
identified with the remote past and past events are identified as recent. 

Places may be incorrectly identified so that the individual may not 
know familiar streets or buildings; or unfamiliar streets and cities may 
be recognized as familar places by the individual. The latter phenom- 
enon is called "the illusion of the deja vu." There seems to belittle 
advantage in distinguishing between the feelings of having seen before, 
having heard before, having touched before, under separate names. In 
normal people, there is usually a conflict between the feeling of familiar- 
ity and knowledge that the experience could not have occurred pre- 
viously. Unless this conflict does occur, the experiences are accepted 
as real. In the psychotic patient the disparity between feeling and 
knowledge seems to be lacking. The normal individual checks on the 
disparity; the psychotic does not. 


The following case presented by Woolley (391) illustrates the con- 
tinuous feeling of familiarity. 

A 26 year old woman for several years has suffered with symptoms of fear of 
blushing and fear of insanity. The family setting consists of father, mother, three 
older brothers, and one younger brother. Following a change of residence and taking 
up work as a housekeeper with a widower who had three children, (two boys and a girl) 
and a male employe residing in the home, she began to have a continuous feeling of 
familiarity with the whole setting. In many respects she was accepted as one of the family 
and ate with them at the table. She was carried to and from treatment in the family car 
and frequently was left alone with the man in the evenings, spending the time talking 
with him. This set of experiences of familiarity was brought up spontaneously by her 
and became associated with her own home setting wherein she was almost in direct 
competition with her mother for the management of the household (which fact had been 
admitted into consciousness in forms of a wish for the mother to be dead and herself to 
have charge of the house). It is interesting in this connection that she had refused several 
positions working for women employers, being finally attracted to the present one. 
She felt sorry for the man because he had a dead wife. He is the one who brings her back 
and forth in the car. She leaves the analytic hour to return home and spend the eve- 
ning with him because she has no where else to go. She is much embarrassed at having 
accepted extra money from him because she needed it. She feels, when she eats with them 
at the table, that she knew them all before and associates this with an experience in which 
she had felt very much embarrassed at the supper table in her own home when she had 
clumsily revealed a secret of her brother's. 

Many psychotics fail to recognize their friends and relatives, and may 
even deny the reality of themselves. Likewise, they confuse their 
nurses and doctors with other people. Specific cases of confusions due 
to faulty recognition would add little to the student's knowledge since 
they happen frequently to almost everyone. The student should bear 
in mind that these confusions are not indicative of incipient psychotic 
condition unless they are exaggerated. Here again, there is no line of 
demarcation that can be satisfactorily drawn. 

Experimental work dealing with recall and recognition in various 
groups of psychopathic people shows that, similar to normal people, 
the loss in recall is greater than the loss in recognition. This seems to 
hold true for senile, paretic, manic-depressive, schizophrenic, epileptic 
and psychoneurotic cases. Not all patients in these classifications show 
amnesia, but when amnesia is present, it affects recall more severely 
than it does perceptual recognition. Arluck (392), in discussing the 
literature as well as his own work on memory in epileptics, reports 
that a number of investigations have shown memory deficiency. In 
his work, which was confined to non-deteriorated cases, he found no 
evidence of memory deficiency on the digits tests, reading test and 
designs test (1936 revision of Stanford-Binet Test). 


The explanation of paramnesias depends upon both theories of 
memory and theories of many of the major mental disorders. It will 
be possible, therefore, to indicate in only a brief manner at this point 
the underlying nature of the disorders. Our explanation will in part 
overlap some of the previous discussion of the various phases of memory. 

Janet considered one form of paramnesia, i.e. "the illusion of the 
deja vu," as a disturbance of perception rather than memory. He 
maintained that it is a false appreciation of the character of the actual 
perception which takes on more or less the aspect of a phenomenon 
reproduced. In other words, Janet implies that the paramnesia is an 
illusion in which false perception occurs. In "the illusion of the deja 
vu," however, the perception seems very vivid and clear, leaving 
little chance for the false appreciation of the character of the actual 

Organic impairment due to fatigue or other causes has been suggested. 
While it is true that paramnesia is encountered in such cases, the actual 
explanation is unsatisfactory because organic impairment is not always 
accompanied by paramnesia. Vivid emotional concomitants with 
previous experiences have been utilized as the basis for explaining cer- 
tain characteristics of paramnesia. A specific feeling tone when aroused 
may reinstate previous experiences associated with that feeling tone, 
and hence the experiences become displaced in time. Many psychotic 
patients are completely out of touch with reality and hence the theory 
that they do not perceive any distortion of memory seems to be plausible. 
Explanation then has to be offered for their loss of reality before a 
satisfactory explanation can be given for the paramnesia. 

Therapy for memory failure has been largely along physiological 
lines. Vitamin B complex, reduced oxygen tension, circulatory insuffi- 
ciency, benzedrine, caffeine, aminophyllin, epinephrine, nicotinic acid, 
and pantothenic acids have been examined as agents that may be related 
to retention. Most of these agents have proved to have some beneficial 
effects, but they do not adequately control memory failure. Glutamic 
acid has been investigated as a potential agent in improving learning 
and in so far as memory is involved in learning it throws some light on 
memory. Marx (400) and Hamilton and Maher (401) have demon- 
strated that glutamic acid in normal or supranormal levels does not 
alter the performance of rats in maze learning. Other authorities have 
reported some improvement. At present, the beneficial effects seem 
limited at least. The reader can obtain an extended account of the 
literature by reference to Muenzinger et al. (393), Bowman et al. (394), 


McFarland (395), Bleuler (396), Forbes (397), Hollingworth (398), and 
Cameron (399). 

Hypermnesia includes several different activities that are related to 
the various phases of memory. When we say that an individual has an 
unusual memory we usually imply that he has an exceptional ability 
for recall. Recall immediately after presentation of material to be 
remembered and recall after a delayed period of time may not depend 
upon the same factors. We tend to distinguish between the number of 
items that can be recalled successfully and the period of time during 
which a given number of items can be remembered. What really con- 
cerns us is the temporal aspect of memory and the numerical span of 
memory for items. We have already shown that these aspects of mem- 
ory differ in cases of amnesia and it is therefore likely that similar differ- 
ences occur in hypermnesia. We also differentiate between the ability 
to remember all things unusually well and the ability to remember only 
certain specific things. We know very little concerning the causes of 
general ability to remember and are accustomed to explain the ability 
in terms of neural organization, which is just another way of stating our 
lack of knowledge. Some authors state that individuals of high in- 
telligence have good memories. All that such statements really mean 
is that in tests of intelligence, memory plays an important part. Mem- 
ory seems to be tied up with imagination to a certain extent and some 
people who have auditory imagery well established are able to recall 
things that they have heard better than the things that they have 
touched or seen. In other cases, touch or vision is more important for 
establishing memory. Why this should be true is difficult to explain. 
Sensory deficiency will not explain the matter, and if the assumption 
is made that some sensory centers in the cortex are superior or inferior 
to others, we have done nothing more than make an assumption. We 
know that a strong emotion accompanying a definite response may tend 
to enhance memory for specific details or may tend to blot out such 
details. Which will obtain is hard to predict. Some theories of learn- 
ing hold that pleasant emotions tend to fix the response, whereas un- 
pleasant emotions tend to inhibit fixation. Both pleasantness and 
unpleasantness at times enhance recall of details of experiences. The 
state of integration existing at the moment of stimulation is probably 
the determining factor as to whether pleasantness or unpleasantness is 
the more potent in the fixation of events that are to be recalled. Shaw 
and Spooner (403) found that there is a form of selective memory which 
depends upon whether the subject is ego-involved. They had subjects 


rate an individual on a number of characteristics. A week later these 
same subjects were read a "bogus" composite rating of the individual. 
A week later they were asked to recall the bogus ratings. Recall was 
better for those items which coincided with the individual's own rating. 

General hypermnesia is never of any serious concern to the individual 
and has received only incidental consideration in abnormal psychology. 
The writer is inclined to the view that hypermnesia is almost always 
specific; i.e. refers to certain particular events or topics. Certain psy- 
chopathic individuals may remember all their sins; others who have 
transgressed just as frequently may not remember their sins but can 
recall in unusual detail all the experiences associated with the various 
illnesses in their lives. We might also point out people who do tricks 
in the theater and have the ability to remember lengthy codes or num- 
bers. So-called lightning calculators probably possess unusual memory 
for mathematical concepts. Meumann (402) cites the cases of the Ital- 
ian, Inaudi, and the Greek, Diamandi. The former had been reared as 
a shepherd and was illiterate until the age of fourteen. He multiplied 
mentally numbers up to 24 digits but had them always presented to him 
orally. He was able to recall the next day all of the mathematical 
operations used in an hour's performance. 

The latter was well-educated, but in contrast with Inaudi, insisted 
that all of his numbers be written. He was able to memorize in a very 
brief time a large column of numbers and repeat them either forward or 
backward. Why these men have such ability and others do not have it 
or cannot cultivate it is one of the problems for further research. 

Some of the problems on association and memory which have been 
treated inadequately in this chapter will receive further elaboration in 
the next chapter, in which the general theories related to the association 
mechanism will be discussed. 



In this chapter we shall present certain theories that have been ad- 
vanced for explaining the disorders which are ascribed to central origin. 
While these disorders have been discussed in part in the chapter on 
Association and Memory, certain more generalized theories that are 
related to the origin of the functional psychoses need to be elaborated. 
The inclusion of certain of the theories does not mean that the theories 
are valid. The presentation of any theory implies only that the theory 
has been held to be valid by its proponents. Some of the theories may 
be useful at present only, as historical curiosities, but their inclusion is 
justified on the basis that the student should know about them so that 
theorizing along similar lines will not be accepted as uncritically in the 
future as in the past. 


Practically all of the psychological theorists admit as the basis of 
normal association the neural arc; that is, afferent impulse, the central 
relay or connecting mechanism, and the efferent impulse. It is an ac- 
cepted fact, moreover, that many afferent impulses reach the sensory 
cortex simultaneously. These manifold simultaneous afferent impulses 
are in some manner organized (integrated or unified) in the brain so that 
a single efferent or relatively few efferent impulses occur. A very good 
example of the function of the integrating mechanism is found when one 
listens to an orchestra playing jazz or classical music. The air or tune 
is perceived as a synthetic product and is not perceived as being made 
up of a series of tones and overtones generated by a piano, saxophone, 
traps, and so forth. Facts from every day experience indicate that these 
response patterns become linked with each other and are remembered. 
The problem of abnormal psychology is to explain just how certain 
associated experiences are lost and how wrong efferent pathways are 
activated in place of the efferent pathways that are usually activated. 

Errors in typing such as "hte" and "upno" for "the" and "upon" 
represent some slight derangement of the integrating system. Likewise 
speech lapses in which syllables are mispronounced or misplaced may be 



of the same origin. These examples occur almost daily, and little at- 
tention is paid to them, since they are only temporary and their impor- 
tance is relatively slight. Examples of loss of events that have once 
been a part of our associated experience are also very numerous. The 
recall of a word, name, or date may be attended by difficulty. The 
word seems to be at the "tip of the tongue," yet it cannot be remem- 
bered. A few seconds or a few minutes later it is suddenly recalled. 
The processes of association have now functioned in their customary 

Exaggerated failure of association and failure of integration take place 
among neurotic individuals. Systematic movements such as stamping 
the foot before beginning to walk, functional paralysis, amnesia, and 
other hysterical manifestations have been explained in this way. 

The specific kinds of neuroses may be disregarded for the present, but 
it is necessary to delve into the psychological theories underlying their 
development. The various theories which will be discussed are: 

1. Dissociation Theory. 

2. Redintegration Theory. 

3. Inattention Theory. 

4. Conditioned Reflex Theory. 

5. Psychoanalytic and Instinctive Theories. 

Although these theories are similar in many respects, the chief differ- 
ence lies in the emphasis placed upon the various factors controlling 
consciousness and motivation. The points of disagreement are of 
sufficient importance to warrant separate treatment. 


The dissociation theory has been identified with Janet and Prince. 
Janet in his two volumes, T.he Mental State of Hy stericals and The Major 
Symptoms of Hysteria gives a lucid picture of hysteria and its symptoms. 
He also supplies the nucleus of the dissociation theory which has been 
elaborated by Prince, Sidis and others. 

The system of psychology as set forth by Janet is not essentially 
different from the modern viewpoints of Dunlap, Hollingworth, Carr 
and others. The functional disorders, according to Janet, arise because 
of a constitutional weakness, predominantly of the encephalon. Cere- 
bral exhaustion results from this weakness, and there is an inadequacy 
of synthesis or dissociation. Since, however, all of the functions are 
not equally exhausted, the functional disturbance involves those func- 


tions that are weakest, and it is only when some stimulus from the 
environment calls into play these weakened functions that the disorder 
is exhibited. It appears that emotional states coupled with these envi- 
ronmental stimuli are highly important. There seems to be embodied 
in Janet's scheme an organic basis for functional disorders, i.e., neural 
exhaustion. He leads one to believe, on the contrary, that the dis- 
turbance is only psychological in origin. He includes in his concept 
of exhaustion a diminution of psychic energy, possibly similar to the 
James* idea of the waning of the stream of consciousness. 

Prince (404) has gone still further in developing the dual concept of 
mental activity. He assumes that conscious activity is accompanied 
by definite neural conditions. All mental activity leaves its traces 
(brain records) in the neural system; these remnants are called neuro- 
grams. The memory for past events is embodied in the vestiges of 
these neural correlates. When these neurograms are again activated 
by a physiological process or by a psychological state (thought, imagina- 
tion), conscious experience may or may not result. This leads to an 
investigation of Prince's idea of consciousness. It is necessary to refer 
to our earlier remarks in this chapter concerning the reaction process 
and the integrating action of the nervous system. For our future dis- 
cussion of the concept of consciousness, Dunlap has given a simple 
and understandable statement. Consciousness or being conscious, is 
awareness or being aware. Obviously, this simple statement needs 
some elaboration. There must be some distinction between the process 
of being conscious, the content of consciousness, or that of which we are 
aware, and the thing that is aware. The first of these terms may be 
applied to the function of the total organism; the second, to the 
stimulus and the third, to the ego or the I. 

Dunlap (405) states that consciousness or awareness varies in degree 
from the "focal" or highly "attentive" on the one hand to the "marginal" 
or "fringe" consciousness on the other. Difference in respect to degree 
(vividness) may exist between consciousness at one moment, and the 
consciousness at the next, and also in any given moment, between the 
consciousness of different details in the content. Whether the gradation 
in degree is of a continuous sort, or whether there are 3, 5 or more dis- 
tinct "grades" between "focus" and "margin" need not enter the dis- 
cussion. He further maintains that the occurrence of the marginal 
degree of consciousness, sometimes termed subconsciousness, is tacitly 
or explicitly admitted. That these forms of subconscious processes 
are important, not only as modifying the total conscious pattern of the 


moment, but also as profoundly influencing succeeding processes, 
both conscious and non-conscious, is also generally admitted. 

The adoption of his concept of subconscious processes does not neces- 
sitate the adoption of the various doctrines of the "unconscious mind" 
or of "co-consciousness" unless the obvious fallacy is committed that, 
since the names of the various concepts are confused, the concepts are 
the same. The differences in degree of vividness or awareness have 
been attributed by different authors to various psychical "entities" 
called the unconscious, the pre-conscious, and the co-conscious. It is 
preferable for the present to term all these different concepts of con- 
sciousness nothing more than degrees of consciousness. What Dunlap 
calls marginal consciousness has been termed subconscious processes 
by others. That subconscious processes or marginal consciousness 
influence focal consciousness can be readily demonstrated. While 
dancing, one may be carrying on a conversation about a beach party 
or changes in style of clothing; however, when the orchestra changes 
from one dance step to another, the steps or movements of the dancers 
are correspondingly changed, in spite of the fact that the tempo of the 
music has not been in focal consciousness. Similarly, if one is engrossed 
in reading, when the dinner hour approaches, he may stop reading, 
although hunger stimuli have not been dominant. Coover's (406) work 
on subliminal stimulation shows that an element in a stimulus pattern 
may be in consciousness, yet not be focal. Cards which contained in 
the center nonsense syllables (in foveal vision) and in one of the upper 
corners a number (in peripheral vision), were exposed to subjects. 
When these cards were exposed for such a brief period of time that 
only the nonsense syllables could be ascertained, it was found that the 
numbers on the cards (in peripheral vision and below the time threshold) 
could be guessed correctly more often than could be expected on a basis 
of chance. If these examples of non-focal or subconscious activities are 
compared with Prince's concept of the subconscious and co-conscious, 
certain differences will at once appear. 

For example, in normal integration (fig. 31) stimulus patterns I, 2, 3, 
4> 5> 6, would produce their respective responses R 1 , R 2 , R 1 , R 4 , R 8 , 
and R 6 . Connections would be established in the central nervous sys- 
tem in such a manner that S.P. I may be linked with 2 and 3, and may 
also be linked with 4, 5, 6. In multiple personality, automatic writing, 
functional anesthesia, and somnambulism, Prince assumes that patterns 
4, 5, 6 become isolated from patterns I, 2, and 3. The vestiges of 
connections through pathways x, y, z remain, although these do not 



function unless some unusual means is employed to reintegrate or 
establish the unity of the system. Not only do these independently 
integrated systems exist side by side, but they may function in conscious 
experience independently of each other. The organization of these 
independent conscious systems centers in an emotional element or 
sentiment. The neurograms which were described earlier as "brain 
records" are purely neurological and have no mental element. These 
dominant neural dispositions are what Prince terms the "unconscious." 
They are the basis for memory. In the following diagram, if stimulus 
pattern 2 produced response R 1 traversing pathway a, then it is assumed 


5. P. 

FIG. 31. Diagram showing the interconnections of stimulus patterns with the response 

that that pathway is effected in some manner or becomes organized in 
some way so that it retains the possibility of action in the same way. 
Originally, the traversing of that neural pathway produced conscious- 
ness, and one might expect that later neural activity of that pathway 
would be accompanied by consciousness. According to the theory 
under discussion this does not always happen. The activity of the 
neurograms may revive all the conscious experiences that took place 
when the original impression was made, or there may be only reflex 
activity of the neurogram which influences consciousness at the moment 
but which is not in consciousness itself. For example, seeing an insect 
in the jam may lead to a dislike of jam. This reaction produces a neuro- 
gram relative to the reaction. At a later time, this neurogram may 
be activated so that seeing flies in the dining room leads to the inability 
to eat any food at that time. The original psychical experience of 


seeing an insect in the jam is not necessarily reinstated, although it 
may be. A description of a case of somnambulism by Jastrow (407) 
brings out clearly the fact that neurograms may be active but not 
conscious. A young woman who was a confirmed somnambulist was 
in the habit of dressing and going from her bedroom to the parlor on the 
next floor. When observed, she struck a match on the under side of 
the mantel and lighted a gas light. She sat in a chair and gazed at a 
picture of her mother. Obstacles interfering with her vision were not 
noticed. Bread soaked in quinine and placed in her mouth pro- 
duced no response. Pinching, tickling, and pulling her hair were 
equally ineffective in awakening her. When finally awakened, she had 
no recollection of her actions. In many neuroses, the difficulty lies in 
the fact that the neurogram influences conscious experience but does 
not revive the associated phenomena. The individual is unable to 
understand the genesis of his dislike for food under the specific cir- 
cumstances. When this is explained by means of analysis of some kind, 
the dislike no longer prevails. 

There is still another important aspect of consciousness inherent in 
Prince's system. To the usual concept of consciousness, he adds co- 
consciousness. Some conscious experiences are separated, because of 
inhibition or conflict, from the total system. Experiences integrated 
with this unit, which may be called "consciousness number 2," are not 
conscious in the sense in which the term "consciousness" is usually 
employed. This type of dissociation of consciousness is best exhibited 
in cases of multiple personality, hypnosis, and functional anesthesia. 
An hysterical subject will deny feeling pin pricks or a hot iron and will 
declare that a loud sound was not heard in spite of the fact that atten- 
tion is centered on the anesthetic arm or on hearing. He will not only 
deny any awareness (consciousness) of these events but also will show 
no observable response to these stimuli. If, however, he is hypnotized 
and placed in another state of mind (consciousness), he will insist that 
sensations occurred at the time of the stimuli. In other words, there 
was a co-conscious perception even when there was no conscious percep- 
tion. The veracity of co-conscious perceptions can be established. The 
patient can tell you the instrument used, the actual number of pricks 
or the number of sounds given, and the procedure used in giving them. 
It is assumed, of course, that the subject is blindfolded and that all 
of his cues are derived from sensations of the anesthetized area. Prince 
held that the motivating force is instinct and when an instinct is aroused 
the organism expends energy in three directions: an attempt is made to 


satisfy the instinct; there is a production of visceral preparatory changes; 
and an inhibition of contrary instincts. Nicole (408) interprets this to 
mean that Prince recognized dynamisms of conflict and antagonism. 
He attributes a departure to Prince from Janet's theory of weakened 
synthesis of neurosis and contends that Prince's concept of dissociation 
is dynamic rather than biologically tinged. 

In cases of multiple personality, one of the personalities may exhibit 
entirely different character traits from those shown at another time when 
the other personality dominates. Information which has been learned 
in state "A'' cannot be utilized in state "B" and vice versa. In auto- 
matic writing the individual may reveal the answers to questions and 
solve arithmetical problems which have been asked, while deeply en- 
grossed in some other task. The individual may not be conscious 
(Dunlap's use of the term is implied here) of either the questions asked 
or the answers given. These examples of simultaneous conscious 
activity seemed to Prince to add further evidence to his concept of 
co-consciousness. More detailed illustrations of this behavior will 
be presented in a later chapter. Although the concept of dissociation 
may be readily understood, the actual nature of the functional disorder 
or the loci of the dissociation are not at all clear. 

One of the authors has attempted to secure some information con- 
cerning the loci of the dissociation in hypnotically induced states. In 
order to determine whether there was a blocking of the afferent pathway, 
anesthesia of the arm and anacusia were induced. Electrodes were 
applied to the subjects to secure changes in skin resistance and body 
potential. Since these electrical changes seem to depend upon sensory 
stimulation and motor activity of localized areas of the body, the intact- 
ness of neural pathways may be inferred on a basis of the occurrence 
or non-occurrence of the electrical changes; for example, if the free nerve 
endings for pain in the arm of a hypnotic subject are not functionally 
connected with the central nervous system, a psychogalvanic response 
(electrical phenomena described above) might not be expected. A 
similar condition might be obtained when hypnotized subjects are given 
suggestions that they are unable to hear anything, or when they are told 
that they cannot remember an event that has occurred in the normal 
waking state and to which an emotional response usually takes place. 
These subjects will, when awakened, deny that they have felt pin pricks, 
have heard a gong or pistol, or have remembered a salacious story. 
Nevertheless, a galvanometric response almost identical with the 
response of the normal waking state is obtained. Typical psychogal- 



vanic responses for the normal and so-called "dissociated" state are 
shown in plate II. 

These experiments indicate that the afferent and efferent pathways 
are intact, since a paralysis of either the sensory or motor nerves by an 
anesthetic such as novocaine or by severing the nerves destroys the reac- 
tion. The psychogalvanic response has been experimentally inhibited 
in subjects with local anesthesia of the fingers. Although the experi- 
ments just set forth establish the fact that no neural blocking occurs at 
the reflex level, they do not demonstrate that a blocking does not take 
place at a higher level which would involve consciousness. In other 
experiments in which amnesia was suggested, and in which conditioning 
was tried, consciousness was involved, or at least the association proc- 
esses were involved. Hypnotized subjects were told that they could 
neither hear a particular sound nor feel a feeble electric shock presented 
simultaneously. It was found that a psychogalvanic reaction was 
secured later when the sound alone was presented. The conclusion 
must be reached, then, that the neural pathways were functionally 
active at the higher levels; otherwise the response would not have been 
secured. Since these so-called dissociated states yield responses prac- 
tically identical to normal responses, it appears that the term "func- 
tional dissoci?tion" is simply descriptive and not explanatory. 


The redintegration theory advanced by Hollingworth is carried over 
with some modifications from the psychology of Sir William Hamilton. 
In addition to offering the best explanation of many functional disorders, 
it is relatively free from the hypotheses, assumptions, and mystical 
concepts embodied in many of the other theories. Hollingworth pre- 
sents a very good account of his theory in explaining a case of anorexia. 
The case may be summarized as follows: A widow whose husband had 
been dead for 3 months showed a loss of approximately 40 pounds in 
weight. The loss in weight was linked with the fact that she had no 
desire to eat; the small quantity of food which she took was chewed 
indefinitely because she felt a constriction in her throat and could not 
summon sufficient courage to swallow it. 

Hollingworth (409) says: 

It is enough to recognize that here is a situation (sitting at the table) which had previ- 
ously been a part of a larger whole (the first occasion of trying to eat after her husband's 
death, with his empty place conspicuous, the odors of medicine, the presence of lamenting 
relatives, the business of the undertaker, the priest, the nurse). In this elaborate situation 
her pronounced emotional reaction prohibited eating, characterized as it was by emotional 


sensations, constriction of the throat, feeling of weight in the stomach, lack of appetite, etc. 
Since then a part of the original situation, namely the act of sitting at the table to eat, rein- 
states the whole emotional reaction. 

Any part of the original situation would probably be equally effective but these parts 
do not recur. The relatives have departed and seldom visit her; the body is gone; the 
undertaker never returns; the house is no longer darkened in daylight. It is entirely un- 
necessary to assume with Dej6rine and Glauckler (the case was originally presented by these 
authors 1 ) that the idea of her husband was present in imaginal form, or induced in any 
conscious form whatever. What is present is a fragment of the original stimulus, evoking 
the total reaction. 

Attention must be called to the normal integrating action of the nervous 
system which was discussed earlier in the chapter. It was stated at 
that point that the organism is aroused to activity by stimulus patterns 
rather than by isolated stimuli. Hollingworth maintains that a single 
element from pattern A, incorporated into pattern B, is sufficient to call 
forth the identical response which was originally made to pattern A. 

The explanation offered is only partially adequate. Difficulty is 
encountered, since Hollingworth fails to take into account the lack of 
rationalization on the part of the widow. Countless other women are 
faced with similar situations; yet they do not develop anorexia. It 
cannot be said that element "a" in pattern B does not recur to them in a 
manner analogous to its recurrence to the women who have developed 
a disorder. All that can be said is that element "a" in pattern B is in- 
tegrated differently by most people. The causal explanation of differ- 
ences in integration is ignored. The development of delusions proceeds 
along similar lines. The individual who develops ideas of persecution 
may have been slighted by some inadvertent action or have been 
offended by some unintentional remark on the part of another indi- 
vidual or other individuals. Later remarks are interpreted as being 
directed toward the individual who develops the delusion. The partial 
situation reinstates the feeling of being slighted. Just why the second 
and later situations are associated with the original situation has yet 
to be discovered. 

In this connection the writer recalls an incident which took place 
some years ago. In carrying out some experiments, he hypnotized a 
subject by the usual method of having the gaze fixed on the experimenter 
while monotonous verbal stimuli were given. The verbal stimuli 
included repeating the numbers from I to 10. This same subject was 
engaged in this laboratory in another experiment which involved cross- 

1 Writer's insert. Case reprinted by permission from H. L. Hollingworth, Abnormal 
Psychology, 1930, The Ronald Press. 


ing out single-place numbers. While performing this task he came 
across the number series from I to 10 and immediately fell into a hyp- 
notic condition. The subject, when aroused, had no knowledge of the 
actual factor involved in his predicament. In fact, he inquired what 
had happened to him. The significant feature of the two situations 
was the number series. In both instances the reactions were the same; 
nevertheless, it is begging the explanation to say that this element 
reinstated the original reaction. The question which must ultimately 
be answered is: why did the individual not perceive that the task of 
crossing out numbers was different from the hypnotic situation? In 
explaining these questions which have been raised, Hollingworth offers 
an intellectualistic interpretation. He maintains that the neurotic 
individual is lacking in sagacity and hence is more prone toward redinte- 
grative reactions. This notion was founded on the fact that many of 
the soldiers in the late war who exhibited neurotic tendencies were 
below normal in intelligence. He is partially correct in his contention; 
nevertheless, there are a great number of neurotic cases that show a 
relatively high order of intelligence. 


The theory of functional disorders proposed by Hurst (410) is worthy 
of comment although he did not attempt to apply his theory to any cases 
except those suffering from hysteria. He states that "hysteria is thus 
a condition in which symptoms are present which have resulted from 
suggestion and are curable by psychotherapy." His point of view is 
similar to that of Charcot, Babinski, and Rosanoff. The elaboration 
of his theories leads him to a rather simple explanation of functional 
disorders of the special senses. It is this aspect of his work that will 
be given our attention. Before discussing the theory in detail, it will 
be necessary to present some information concerning a few of his experi- 
ments. Hurst attempted to determine what factors were responsible 
for the production of hysterical anesthesias. He assumed that the ma- 
jority of these cases arise because of the nature of the questions asked 
by physicians during their examinations. Then he selected 29 healthy 
and intelligent medical students who had had no clinical medicine and 
asked them to pretend that they had been in a railway accident and 
that they were trying to collect indemnity because of a paralysis of the 
right arm and leg. When these men were asked if they suffered from 
any other symptom, they uniformly denied other injuries, a procedure 
which corresponds to the behavior of patients with hysterical paralysis. 


They were then asked, "Can you feel as well on your right side as on 
your left?" Twenty-two of the 27 complained of feeling less on the 
paralyzed side. When these men were tested, 6 had right hemi-anes- 
thesia, 5 had complete right hemi-anesthesia except the face, twelve had 
anesthesia of the whole arm and whole leg, one had hyperesthesia of the 
whole arm and whole leg, and 4 had no anesthesia. It appears then 
that the mere asking of a leading question will influence the actual 
sensations of normal individuals. 

According to Hurst there are three classes of anesthesia: (a) in which 
the anesthesia is produced by a suggestion of the physician, (b) in 
which the anesthesia is produced because of inattention to dermal sensa- 
tions during some other profound disturbance, (c) in which the anes- 
thesia arises because of an organic injury. The anesthesia is complete 
during the organic injury, but auto-suggestion is responsible for the 
lack of feeling after the recovery of the nerve. 

Hurst and his co-workers have demonstrated that even in the cases 
of organic disturbances a leading question will produce symptoms anal- 
ogous to those found in hysterical patients. Patients who have a defi- 
ciency in hearing due to organic causes, which is the same for both ears, 
will readily admit that the acuity is better in one ear if they are 
asked which ear is better. Functional loss of hearing, vision, touch, 
warmth, and cold may be explained on a basis of suggestion. The indi- 
vidual cannot feel, see, or hear because of inattention to peripheral 
stimulation. Inattention may be brought about through any one of 
the three methods listed above. For example, an individual may be 
unable to hear well when he has a head cold. Auto-suggestion leads 
the individual to cease paying attention to sound stimuli after recovery 
from the cold. Another individual may not hear when spoken to if he 
is suffering from some profound emotional shock. Attention is directed 
to his cogitations which involve the emotional experience. Sounds 
after the emotional crisis has disappeared are not heard because of 
auto-suggestion in connection with the emotional experience. Still 
another individual may be influenced by suggestions of the examiner 
in a way which has previously been described. Hyperesthesia is ex- 
plained by a reverse mechanism. Attention becomes fixed or centered 
on certain peripheral stimuli by suggestion. 

The difficulty with Hurst's theory is that he attributes some "volun- 
taristic" role to attention. In other words, he assumes that attention 
requires some voluntary neural "set." Individual variation has not 
been explained. Why certain individuals should be more suggestible 


than other individuals remains to be explained. The only hint which he 
offers in answer to this question is that hysterical symptoms are more 
prevalent in the less intelligent and less critical individuals. This cor- 
responds to Hollingworth's "intellectual concept." 


The conditioned reflex theory as applied to abnormal behavior has 
been set forth to a large extent in the works of Bechterev and Pavlov. 
Developing simultaneously and long somewhat similar lines have been 
the experiments and writings of the behavioristic school of psychology. 
The pronouncements of Watson, M. Meyer, Hunter, Lashley, and Weiss 
may be considered as representative of the tenets to which the behavior- 
istic must subscribe. 

A reflex, according to Pavlov (41 1), is based upon strictly neurological 
and physiological factors. The receptor or sense organ is a specialized 
type of cell or cell-group appropriate for responding to different kinds 
of stimuli. This is connected with the central nervous system in the 
usual way. The sensory nervous impulse is then directed towards the 
effectors so that a response occurs. Thus far, this conception of the 
reflex activity does not differ from the reaction arc hypothesis as stated 
by Dunlap. The subsequent explanation concerning the particular 
efferent pathway traversed gives rise to a divergence of the two theories. 
If we may naively assume for purpose of clarity that the individual is 
born before receiving any stimulation, then the first stimulus which he 
receives will produce a response. The nature of this first response will 
be determined by the development of his neural structure. The second 
response made by the organism may be initiated by the first response; 
the third response, by the second; and the later responses by those 
preceding them. Unfortunately, the stimulus-response situation soon 
becomes complicated, and the problem of explaining selectivity of re- 
sponse, linking of responses, and substituting responses must now be 

The unconditioned response made to a particular stimulus is deter- 
mined by the structure of the neural system and other modifying physi- 
ological conditions. The only restriction placed upon simple reflex 
action in the normal individual is that the initial response is always 
appropriate or biologically useful for the animal. In the total structure 
of the nervous system there are innumerable innate reflex arcs which 
await the proper stimulus to set them into action. This innate disposi- 
tion is in itself sufficient to account for the selectivity of response, 


according to Pavlov. For example, he assumes that the reflex arcs 
involved in the withdrawal of the hand from a pain stimulus, or the con- 
traction of the pupil when a light is flashed upon it, arise in the above 
manner. The aggregate of all these reflexes constitutes the foundation 
of the nervous activities of all the higher organisms. Linking of 
responses occurs in the manner which was described previously, i.e. 
the response of one reflex action serves as the stimulus for the next 
reflex action. A reflex in which the response has been attached to a 
substitute for the natural stimulus, Pavlov calls the conditioned re- 
flex. For example, when a puff of air is directed on the eyelid, there 
is a closing of the eyelid, a natural reflex. If another stimulus such 
as a sound, which by itself has no effect on the lid reflex, is presented 
along with the puff of air, the sound after a few repetitions will have 
the same effect, namely, closing of the eyelid. This conditioning proc- 
ess does not occur except under the following circumstances. 

1. The conditioned stimulus must overlap in time the action of the unconditioned 


2. The conditioned stimulus must begin to operate before the unconditioned stimulus 

comes into action. 

3. Other distracting stimuli must be eliminated. 

The opposite aspect of conditioning or the breaking down of the 
conditioned response Pavlov refers to as inhibition. Inhibition seems 
to be the tendency for conditioned responses to return to their uncon- 
ditioned or primal state. In other words, a conditioned reflex will be 
weakened (inhibited) if the repeated application of the conditioned 
stimulus is not reinforced. If reference is again made to the condi- 
tioned lid reflex, the inhibitory effect can be made more explicit. The 
continued repetition of sound tends to lose its effectiveness, unless 
the original stimulus of a puff of air be interpolated. Another factor 
controlling inhibition is the intensity of the excitatory process. In gen- 
eral, the greater the intensity of the excitatory process, the more intense 
must be the inhibitory process to overcome it. 

The application of the conditioned reflex theory to problems of abnor- 
mal psychology is linked up with Pavlov's explanation of sleep and hyp- 
nosis. Under normal stimulation, the cortical elements sopn become ex- 
hausted with repeated stimuli, which results in a state of inhibition. The 
real cause of inhibition, then, is exhaustion rather than some specific 
property or function of the cells as was previously suggested. During 
Inhibition the cells recover, since they are free from action. The 


exhaustion may be localized initially but spreads rapidly to adjacent 
cortical areas. These adjacent areas are now in a state of inhibition as a 
result of irradiation. Sleep occurs when irradiation from inhibitory 
regions or pathways spreads over the entire cortex and lower portions 
of the brain. Pavlov further holds that even during the waking state, 
scattered sleep exists in the form of internal inhibition of separate cellu- 
lar groups. The internal inhibition in the alert state is restricted, how- 
ever, from spreading or becoming irradiated by the antagonistic nervous 
process of excitation. 

Hypnosis is explained on a basis of cortical inhibition alone; inhibition 
is not as widespread as in sleep. In one of the experiments with dogs, 
it was noticed that the animal began to show signs of drowsiness, as a 
result of being left in the room without the application of conditioning 
stimuli. The monotonous stimuli of the surroundings led to inhibition 
which gradually spread to the whole brain until the inhibitory effect of 
the environment became so intense that the animal had to be aroused 
before the experiments could be started. When the conditioned stimuli 
were applied immediately, the normal conditioned reflex was present. 
If, however, the application of the stimulus was delayed for a few min- 
utes, the conditioned secretory effect was present, and the salivary secre- 
tion was augmented with the presentation of food, although the animal 
would not voluntarily take the food. In some of the animals, the re- 
flexes disappeared, the skeletal muscles relaxed and the animals snored; 
in other animals, behavior similar to hypnotic behavior in humans was 
observed. The animals would not respond to the conditioned stimuli; 
nevertheless, they preserved an alert posture; the eyes were wide open 
and immovable; the skeletal muscles were semi-rigid, and if one of the 
limbs was placed in a new position, this position was maintained. In 
hypnosis the cortical areas alone are inhibited, as contrasted with sleep 
in which both cortical and subcortical areas are affected. As the hyp- 
notic condition increases, turning of the head, bending the neck and 
movements of the trunk disappear. 

In still other experiments with dogs, conditions analogous to those 
ound in psychopathic people have been found. The basis of the ex- 
planation of these abnormal behavior traits of dogs lies in the inherent 
neural structure of the animal. For the experiments, animals that 
exhibited either unusual amount of motor activity or very little spon- 
taneous activity were selected. The former type of animals possesses 
a neural system that does not readily develop or pass into a state of 
inhibition; the latter type is prone to inhibition; that is the nervous 


functions are in more or less of a state of inhibition all the time. Neuras- 
thenia occurs when the animal passes into a chronic state of inhibition. 

Neurasthenia, according to Pavlov, occurs in those persons in whom 
there is an exaggeration of the excitatory processes. This exaggeration 
leads to exhaustion, since inhibition does not take place quickly enough 
to prevent depletion of the excitatory processes. Hysteria arises in 
those cases in which the inhibitory processes predominate. In order to 
account for the violent attacks of excitation which are sometimes evi- 
dent in hysteria, Pavlov maintains that they are due to a sudden change 
in the excitatory state which persists for a very brief period. Since 
there is a tendency for the nervous system in these patients to be weak, 
a quick reversal to inhibition takes place. This inherent weakness of 
the nervous system also accounts for the indirection and poor synthesis 
of the excitatory processes. 

Reports of two other nervous disturbances of the experimental ani- 
mals and their comparison with human disturbances are interesting. 
Pavlov cites an experiment performed by Rickman in which the dog 
could not stand any strong conditioned stimuli; the conditioned response 
could not be elicited except by very feeble conditioned stimuli. The use 
of strong stimuli caused the animal to pass immediately into a state of 
inhibition comparable to that of a patient reported by Janet. A young 
female patient showed no signs of activity during the day, lying motion- 
less, refusing to eat, and failing to attend to excretory functions. 
During the night when the strong excitatory stimuli were absent, the 
patient was observed to eat and even write. This case shows extreme 
weakening of the cortex which led to development of almost complete 
inhibition under the influence of any strong stimulus. 

The explanation of certain illusions in humans may be inferred by 
having recourse to one of the experiments performed by Erofieva (re- 
ported by Pavlov). A summary of Pavlov's account of the experiment 

A dog in which a part of the sensory cortex on the right side had been 
extirpated showed signs of misinterpreting stimuli falling on the retina 
of the left eye. When the experimenter or even food came within the 
field of vision of the left eye the animal would turn, run away and behave 
in a highly excited manner. The dog would sometimes glance to the 
left and run madly away. The animal's behavior was normal, however, 
when an object or a person came within the field of vision of the right 
eye. Pavlov interprets this behavior as due to the irritating effects 
of the scar tissue on the visual analyser on the one side. In other words, 


since the external stimuli became distorted through the irritating effects 
of the scar, the animal behaved in a manner analogous to the behavior 
of a normal animal to any unusual visual stimulus 

The objections to the conditioned reflex theory as a system for 
explaining normal behavior are expounded in many of the elementary 
text books on psychology. The criticisms that apply to the methods 
and technique of Behaviorists in formulating the general behavior of 
organisms need not be considered here; only those aspects directly 
related to the development of abnormal behavior are of any concern to us. 
The experiments which have been considered thus far have been done 
with dogs and perhaps with dogs that already had abnormal tendencies 
of behavior. Pavlov states in some of his experiments that the animals 
were selected because they showed either an excessive activity or a 
decrease in activity. From the fact that conditioning to isolated stimuli 
in a particular fashion occurred, it cannot be argued that complex 
stimulus patterns would produce like results. One of the essential 
requisites for conditioning is an absence of distracting stimuli; never- 
theless, man is constantly being subjected to unfavorable stimula- 
tion. It seems a little far fetched to argue that since dogs under 
isolated experimental conditions behave in a particular way, that 
humans under still other circumstances will behave in a similar fashion. 
Even the basis of neurotic behavior in dogs is attributed to an innate 
neural disposition, the nature of which is a tendency to excitation or 
inhibition. These are assumptions upon which Pavlov's whole struc- 
ture is founded. If his assumptions are correct then we may infer that 
neurotic humans are neurotic because they are born that way. There 
are certain other internal difficulties inherent in Pavlov's scheme, but 
they are not of especial significance for explaining abnormal phenomena. 

The rather simple theories of Pavlov and his school, which served as 
the stimulus for this whole movement, have been greatly modified and 
no single, dominant and orthodox theory of the conditioned reflex 
obtains at present. Almost every writer has his own particular view of 
the matter and his own innovations to introduce. 

Conditioned reflex theory must be differentiated from the conditioned 
reflex method. As a method it can be used to assay the behavior of 
many different animal forms, including the human, under conditions 
which are fairly rigidly controlled, without necessarily indicating the 
theoretical bent of the experimenter. Masserman (412), for example, 
has often used the method in his explorations of abnormal behavior in 
the cat, but he does not subscribe to any form of conditioned reflex 
theory, which he tends to describe in unfavorable terms. 


A number of investigators have used the method in studying abnormal 
behavior. Welch and Kubis (413) studied normal college students and 
anxiety types of psychiatric patients in terms of the conditioned psy- 
chogalvanic response. They found characteristic differences in the 
rate of conditioning (the anxiety patients conditioning more rapidly) 
and in resistance to extinction (the anxiety patients showing a tendency 
for conditioned responses to persist longer than in normal subjects). 
These results might provide several hypotheses to guide future work. 
It may be that the neurotic and the psychotic individuals break down 
under usual traumatic experiences because of some fundamental differ- 
ence between their nervous systems and the normal nervous system. 
The difference is manifested by indicators of autonomic activity, such 
as the PGR. It is conceivable that people endowed with such nervous 
systems (or such biochemical balances) might become conditioned more 
readily to emotional situations, and might be more resistant to extinc- 
tion of emotional behavior. This would be in the line with Gantt's 
(414, 415) finding that the cardiac component of the conditioned re- 
sponse is more stable and more difficult to extinguish than the motor 
components. This, according to Gantt, is the basis for conflict: overt 
behavior is adaptive, the motor components of the total conditioned 
response being relatively easy to extinguish, but the cardiac components 
(and possible other autonomic responses) are not very adaptive, being 
resistant to extinction. The result of this divergence of functioning in 
the organism is conflict, since there may be good overt adjustment to a 
situation, but emotional responses persist from some previous con- 

Liddell and his coworkers (416) have studied for years the develop- 
ment of experimental neurosis in sheep, goats, and pigs, following 
Pavlov's description of the experimental neurosis in the dog. The 
assumption is that the breakdown which occurs in experimental neuroses 
in animals is in some way related to neurotic episodes in human be- 
havior. Opinions differ as to whether the experimental neurosis is a 
"true neurosis" or a "preneurotic affective disturbance". The investi- 
gators who are working in this field believe that careful study of experi- 
mentally induced neurotic behavior will throw some light on the genesis 
of neuroses and on various factors which may influence their subsequent 
course. Obviously there will be no perfect parallel between animal 
neuroses and human neuroses because of the tremendous differences in 
the importance of, among other things, symbolic processes and social in- 
fluences in the behavior of human and infrahuman forms. But the 
method seems to be a fruitful one, and can undoubtedly throw some 


light upon problems of abnormal behavior if one maintains a reasona- 
bly cautious attitude toward the interpretation of animal syndromes. 

Liddell (417, 418) has come to the conclusion that the classical con- 
ditioning procedure as developed by Pavlov is essentially a traumatizing 
procedure. He thinks that the central factor in the experimental 
neurosis is not so much a difficult or insoluble problem as the self- 
imposed restraint (due to training in the laboratory situation, where the 
animal ordinarily stands quietly in his harness) and suppression of 
spontaneous activity. He finds that sheep who are presented with 
maze problems much too difficult for them do not break down, but 
adjust by procrastinating or evading the situation calmly, whereas 
sheep in a conditioning situation will exhibit the usual experimental 
neurosis. One is tempted to see in this a parallel to the presumed 
effects of repression in human patients, but as we have pointed out 
above this type of theorizing is questionable. A second factor which 
Liddell deems important in the production of experimental neuroses is 
the monotonous repetition of inevitable but trivial reinforcement. 

A number of patterns of neurotic behavior have been described, and 
they are cited here merely to indicate the diversity of "symptoms" 
possible in lower animals in limited situations. Liddell has found 
stiffening amounting to virtual immobility in the foreleg of the sheep, 
not too dissimilar to hysterical paralysis, and a concomitant hyper- 
sensitivity of the foreleg, again not too dissimilar to hysterical hyper- 
esthesias. The rigidity may persist for years. Likewise, investigators 
have found tantrum behavior, somnolence, manic excitement, unwilling- 
ness to eat, and avoidance of the experimenters. 

Gantt (419), who followed the course of behavior in an experimentally 
neurotic dog for 12 years, found that the symptoms changed over the 
course of years, and a large number of responses became involved in the 
neurotic complex, including urinary and sexual responses to the experi- 
mental situation and even the people associated with it. 

Other experimenters have used the conditioned reflex method in 
studying various aspects of abnormal behavior, for example, Masserman 
and Jacques (420) have studied the effects of electro-shock on experi- 
mentally neurotic cats, and Masserman, Jacques and Nicolson (421) 
have studied the effect of alcohol on experimentally neurotic cats. 
Gellhorn (422) has investigated the effect of insulin hypoglycemia and 
electro-shock on the conditioned response in rats. 

The method has proved productive of research on basic problems in 
abnormal psychology and has also suggested many working hypotheses 


which may be tested. The conditioned reflex theory (or "response", 
as it is commonly referred to in contemporary psychology) is not as 
easy to present or to evaluate. As we have indicated, there is no 
unanimity of opinion as to what constitutes the orthodox theory. For 
Pavlov, conditioning was pure associative learning. Most contem- 
porary investigators who consider themselves to be in the field of con- 
ditioning theory have given up this aspect of the theory. 2 Guthrie 
(424) is a notable exception in that he explains all learning in terms of 
strict association or contiguous conditioning. Other prominent theorists 
in the field have introduced motivational factors into the basic theory, 
[Hull (425), Spence (426), Mowrer and Lamoreaux (427)] which require 
that some drive reduction (primary or secondary) occur in order that 
certain responses acquire greater habit strength than others. There 
are at least three trends in current theorizing about conditioning. One 
group, [Hull, Spence, Mowrer, and others], holds that all learning is 
conditioning in a rather strict sense, and there is implied a corollary 
to the effect that all learning follows the same course and is subject to 
exactly the same laws. That is, all psychological functions change in 
identical fashion, and if the laws for one function or complex of func- 
tions and for one animal form can be worked out, any kind of learning 
can be predicted. This may or may not be true, but it is an interesting 
attempt at integration and is productive of much research. In particu- 
lar, Mowrer's research (428) on avoidance conditioning, and his ex- 
planation of the efficacy of this procedure as a reduction of fear, have 
possibilities for the interpretation of neurotic behavior in human pa- 
tients. According to this type of reasoning, neurotic behavior would be 
perpetuated long after the primary causes had ceased to operate since 
the symptoms (the conditioned responses) reduced the anxiety brought 
about by the conditioned stimulus, not because the original primary 
reinforcement ever recurred again. It is a very tempting theory be- 
cause it explains so nicely the seemingly senseless persistence or repeti- 
tion of symptoms, particularly compulsions. 

A second group of theorists are attempting to show that conditioning 
and trial-and-error learning are not essentially different. The emphasis 
seems to be placed on the fact that conditioning is a sort of compressed 
trial-and-error learning. 

2 The Brogden, Lipman and Culler experiment (423) showed no conditioning in 500 
trials when the conditioned stimulus was always followed by the unconditioned stimulus, 
but rapid conditioning was evidenced when the animal made the proper response to the 
conditioned stimulus and was able to avoid the unconditioned stimulus (shock). 


A third point of view, held by Maier (429), is that conditioning and 
trial-and-error learning are different, and further, that learning new 
responses may require a very different technique than breaking old 
ones. In particular Maier feels that fixations are better altered by 
guidance and that trial-and-error is not a particularly effective tech- 
nique. This might have implications for therapy in compulsive dis- 
orders. Mowrer's theory gives one possible explanation of why guid- 
ance would be more effective in such cases. 

There is no one conditioning theory to accept or reject, unless one is 
committed to a theory which denies that any aspect of abnormal be- 
havior is learned. If one follows a school which equates conditioning 
with learning, then conditioning will play an important part in the 
development of abnormal behavior, and a study of conditioning proc- 
esses may eventually throw light on etiology. If one thinks that 
conditioning is different from some other types of learning, it may still 
be useful in interpreting certain data, as in Maier's experiment. There 
remains the further possibility that one may reject the whole concept 
that conditioning in any form ever occurs. Those authors who reject 
the whole concept are apparently reacting to what they consider to be 
an undue simplification and "mechanization" of a complex problem. 
It is possible that certain specific hypotheses arising from the investiga- 
tions of conditioning theorists will be valuable in guiding future research 
in the etiology of abnormal behavior and in therapy. 


A system of psychology that has attracted much attention both 
favorable and unfavorable is that designated as psychoanalysis. Many 
of the orthodox psychologists have been unwilling to admit that it is a 
system of psychology but refer to it as a system of metapsychology. 
Before passing judgment on the validity of the theories held and 
assumptions which underly psychoanalysis, it is desirable to set forth 
the system. 3 The first postulation which is made is that of some innate 
disposition, impulse, urge or striving toward a goal. Freud (430) assumes 
this impelling force or urge to be centered in the sex urge or sex 
instinct, which at one time he called the libido. In the later develop- 
ment of his ideas, the id becomes the great storehouse of the libido. 

3 The student should consult the works of Healy, Bronner and Bowers: T'he Struc- 
ture and Meaning of Psychoanalysis; Wood worth: Contemporary Schools of Psychology; 
Jastrow: <fhc House that Freud Built, and Sears: Survey of Objective Studies of Psycho- 
analytic Concepts. 


At some points in his discussion, it appears that he restricts the meaning 
of sex striving to the conventional meaning, i.e., sex desire of a highly 
specialized nature. At other points of his writing, the nature of the sex 
striving or sex expression includes not only the conventional sex desire, 
but a host of other feelings and sentiments connected with the pleasure 
principle of love. The ordinary physical sex drive is combined with a 
psychic life principle. All conduct for Freud is motivated by these 
wishes or urges, whether they are voluntary or involuntary. Slips of 
the tongue, inability to recall a name, dreams, thumbsucking, bodily 
functions including elimination of waste products of the body, walking 
up and down stairs, acting, studying medicine, etc., are all the results 
of the sex urge which has been altered by various other mechanisms that 
he has postulated. He did not stop, however, with the narrow concept 
of sex urge; he broadened it to include what is conventionally termed 
love, affection, all forms of pleasure and esthetic appreciation. The 
term libido was assigned to this more comprehensive concept. It must 
be remembered that the libido is dynamic in nature and that it nor- 
mally tends to express itself in overt activity. Nevertheless, it is without 
power to direct the course of its expression. 

Sears (431), in his excellent monograph, undertook to evaluate the 
known facts relative to this keystone of the Freudian system. He 
maintains that Freud's system depends upon the acceptance of some 
source of energy such as the libido, and to question this assumption 
would destroy the system. He prefers, therefore, to adopt this source 
of energy tentatively as the basic factor in personality dynamics. He 
examines the facts related to sexual behavior and attempts to ascertain 
whether the facts fit the assumption made by the analysts with reference 
to the way in which sex behavior develops. 

According to Freud and some of his followers, the libido is first 
localized in erotogenic zones other than the genital zone. The child 
obtains gratification by oral and anal erotism. When these sources of 
gratification are interfered with or removed, substitute behavior of an 
anomalous kind arises. Sears has brought together relevant literature 
on this point. The work revolves about the occurrence of thumb 
sucking, nail biting, and oral gestures under conditions of deprivation 
or partial deprivation of oral gratification. In comparing finger suckers 
with non-finger suckers, he found that the former group had histories 
of greater deprivation of opportunity to suck during the feeding process. 
This does not imply a lack of nutriment but only a deprivation of the 
pleasure that was desired from sucking, since puppies fed with a large 


nipple (hence less sucking for satiation) showed a much greater tendency 
to suck at each others' bodies between feeding than animals fed with 
a small nipple (same amount of food but longer sucking time). Sears 
concludes with respect to finger sucking that "nonnutritional sucking, 
either of the food source or of the fingers, seems to be motivated by 
some drive other than hunger. 

Finger sucking is a preferred form of nonnutritional sucking because 
of its autoerotic quality; i.e., the fingers have taken on erotic properties 
as a consequence of chance encounters, and the child therefore gains 
double pleasure, part from fingers and part from mouth. Levy's 
finding that children who used their fingers did not use pacifiers is 
suggestive, but scarcely conclusive because of the nature of the methods 
by which his data were obtained. Continued work on the problem of 
whether the type of feeding and nursing has a significant influence on the 
oral drive and the development of substitute behavior has been reported 
by Simsarian (432) and Sears (433). Simsarian found that complete 
nursing satisfaction at the breast and self-regulation of feedings does not 
prevent the development of thumbsucking. Sears compared the effects 
of cup, bottle, and breast feeding during the first 10 days of life, on the 
development of the oral drive. He concluded that breast feeding 
resulted in the greatest increase in strength of sucking response. He 
theorizes that the oral component of the libido is in part the result of a 
nearly universal method of feeding. In nursing, the child must suck 
and be orally stimulated while securing primary satisfaction. 

With regards to nail biting and oral gestures (touching or manipulat- 
ing the mouth) the data do not seem to confirm the thesis that these 
habits are derived from any form of deprivation or that they afford 
the individual oral gratification. In fact Jones' (434) study shows 
that boys doing mental arithmetic resort to an increase in oral gestures. 
This observation suggests that oral movements are not uniquely related 
to oral erotism. According to Freud, anal sensations give rise to erotic 
feelings, and diarrhea or constipation may be a direct result of fixation 
on this method of erotism or its failure to develop. Koch (435) reported 
by Sears found that constipation was related to the frequency of oral 
gestures by children, and we might infer some support for Freud's idea. 
Koch, however, maintains that emotions of many kinds reduce gastro- 
intestinal activity and also provoke nervous gestures. 

As the child develops, other specialized instinctive tendencies arise. 
Some of these may be diametrically opposed. These special tendencies 
Freud has called the life instinct (eros) and the death instinct. The 


eros is the race preservative instinct. It also comprises the uninhibited 
sexual gratifications and self preservative impulses. The "death" or 
"destructive instinct" is the tendency to reestablish a state of things 
which was disturbed by the emergence of life. It comprises the regres- 
sive tendencies, those impulses to reinstate an infantile or earlier level 
of personality, "self injuring and self destroying impulses." 

The child is born not only with the instinctive tendencies toward the 
gratification of the sex urge, but also with another set of instinctive 
tendencies which act in opposition to and are a part of the libido. The 
early manifestations of activity of the child allow the libido relatively 
free expression. Pleasure of a purely sexual nature is derived from 
natural bodily functions such as nursing and possibly from viewing the 
body of the father and mother. Later in life the activities change, and 
the sex desire is directed toward some other person or objects in the 
environment. This change in the direction of the manifestation of 
the libido must be produced by something, hence the postulation of 
another tendency. This tendency or these tendencies were labelled 
the ego-instincts, or dynamic forces which prevent the organism from 
coming into too direct a conflict with the environment. The ego now 
becomes the repressing force of the libido tendency in spite of the fact 
that it comprises certain libidinous tendencies. Derived from the id 
by modifications imposed on the id by the external world, it is partly 
conscious and partly unconscious in contrast with the id which is 
entirely unconscious. 

If we consider the psyche as embracing both the id and the ego, that 
portion of the psyche that comes into contact with the environment and 
mediates the strivings of the id is called the ego. The ego in the child 
is poorly developed; as the id comes more and more into conflict with 
the environment, the ego develops and in a way protects it. The ego 
plays the role of censor. In sleep its function is partially relaxed al- 
though it is never completely off guard. This accounts for the fact 
that dreams occur only in disguised forms. The latent content of 
dreams is unacceptable to the ego; and although the manifest content 
is representative of the hidden content, it is unobjectionable. 

The third entity postulated is the super-ego and corresponds in 
ordinary terminology to conscience. It is a system of moral tenets. 
The super-ego develops from the ego, although it is to a large extent 
unconscious. Woodworth gives a good account of its development in 
his book entitled Contemporary Schools of Psychology. The super-ego 
is truly an entity. In its early life the child gains expression of its sex 


urge through its own body. The child's early libido centers about oral 
and anal gratification. Nursing, excreting and stimulating the erogen- 
ous zones through movement fill the necessary requirements. Follow- 
ing this autosexual stage, the libido becomes directed toward some other 
object or some other person. The persons most accessible for this 
purpose are the parents. This infantile attachment of the boy for the 
mother and girl for the father gave rise to Freud's notion of the Oedipus 
and Electra complexes. The baby boy's libido is for a while encouraged 
by the natural processes involved in rearing the child. Ultimately 
conflict with the mother develops, since the youngster must be weaned 
and autoerotic and other habits corrected. These conflicts with the 
mother lead to an attachment to the father who becomes the boy's ideal. 
His attachment for his father, however, is not satisfactory since he finds 
certain prohibitions. His father is his rival for his mother. The solu- 
tion to this problem lies in shattering his attitude toward the father and 
wishing him dead or removed. Since this goal cannot be obtained, he 
must repress. Percepts developed as a result of such repressions are 
the essential elements of the super-ego. Even if the child becomes 
conscious of the attractions for the parent and succeeds in repressing 
the libidinous urge or desire, the urge is still there tending to motivate 
the individual towards its goal. Since this cannot be accomplished in a 
direct way because of the interference of the ego and super-ego, the 
urge is manifested in an indirect, round about way which will be accept- 
able to these dynamic entities. 

Data concerning some of the concepts under discussion are to be 
found in the various studies mentioned in the following section. That 
stimulation of the genitals occurs at an early age is confirmed by the 
studies of Blanton (436) and Halverson (437). Sears maintains, how- 
ever, that the observations on tumescence and detumescence do not 
prove whether these activities afford sexual pleasure. Detumescence 
by inference seems to be related to pleasurable sensations of relaxation. 
Sears (438) states in his conclusion concerning erotogenesis that "the 
notion of erotogenesis boils down to little more than the presumption 
that several sources of pleasurable stimulation are somehow related 
to one another. In working out the details of this relation, Freud 
first applied the properties of adult genital sexuality to infantile activi- 
ties centered around the oral and anal-urethral body zones and then 
assumed that there was a specific quantum of pleasure-seeking that 
could be channelized through the various zones, making one a substitute 
for another. The evidence cited here supports the general correctness 
of the first point, but throws less light on the latter." 


Aside from the importance of these pregenital forms of stimulation, 
Freud attaches significance to premature genital sex experience in 
bringing about perversion, hypersexuality and neurosis. The literature 
that has a bearing on this problem has been assayed by Sears. He has 
examined the importance of such factors as early sex play, sex curiosity 
and overstimulation, and sexual aggressions. Work of Isaacs (439) 
and Hamilton (440) indicates that sex play is very common among 
normal children of preschool age and that shame and loathing play a 
part in giving up infantile sexual aims. Prepubertal sex play is reported 
by about 10 per cent of adults although this percentage is likely to be 
modified significantly by cultural conditions as has been observed by 
Malinowski (441). 

In tying up anxiety and aversion with sexual curiosity, the work 
of Terman (442, 443), Landis (444), Conn and Kanner (445), and 
Conn (446) may be cited. All of these studies indicate that curi- 
osity about the differences in the sexes, the origin of babies, and 
similar matters exists among a great many children at an early age. 
The reports do not, however, show how emotional reactions to this 
curiosity are tied up with perversions and hypersexuality. The problem 
of the effect of early sex aggression on subsequent adjustment has been 
studied at least indirectly by Terman, Hamilton, and Landis (reported 
by Sears). Inadequacy, or lack of orgasm, on the part of the female 
is considered a sexual abnormality brought about by inhibition. The 
results of these studies are, however, not in agreement. Terman and 
Landis feel that lack of orgasm and neuroticism occur about as fre- 
quently in people who had early shocking sexual experience as among 
people who did not have such experience. Sears (447) concludes that 
"several sources of evidence indicate, however, that Freud seriously 
overestimated the frequency of the castration complex and the im- 
portance of childhood sex aggressions. The castration complex, like 
theories of the origin of babies, is a function of the kinds of information 
children have. Freud's tendency to rely on cultural universals which 
do not exist has led him to postulate universal attitudes and complexes 
that can be demonstrated in but a part of the population. 

"The influence of sex aggression is not universal, either; but the 
prevalence of perversions, neurosis and morbid prepossession with 
sexual matters that Freud attributed to such experiences can be 
accounted for differently. These experiences are outlawed in our own 
culture and the child who has them, either willingly or unwillingly, is 
made to feel guilty or ashamed; at the very least he knows he must 
not let his participation become public knowledge." 


We shall examine the experimental literature dealing with one other 
phase of Freudian Theory, namely, the object of attachment of the 
sex drive. There are three primary sources of attachment, the self, 
the father and the mother. Primary sexual attachment to the self is 
exhibited by narcissism and masturbatory practices. That such 
early practices do occur is evident from many reports, but that they 
have any special significance in formulating the course of later sexual 
activities is highly dubious. Parent preference is indicated by the 
studies of Stagner and Drought (448), Terman, and Stott (449). All 
of them emphasize the fact that there is very little difference between 
the sexes in the attachment or preference for each parent. Bell (450) 
found, however, that love affairs of children were in some instances 
highly sexualized, but these were outside the family. The studies 
cast doubt on the universality of the Oedipus situation and show that 
forces other than the immediate family relations may serve as the basis 
of anxiety in future love relations. 

The terms "unconscious," "preconscious" and "conscious" indicate 
another division of mental life according to Freud. These divisions 
do not represent any form of dynamic activity but represent the various 
levels at which the id, ego, and super-ego function. 

Thus far, Freud has postulated: (i) The id which is a source of 
instinctive energy, is unconscious, amoral, illogical and centers in 
the sex instinct. (2) The ego, which has instinctive tendencies of its 
own. It is influenced by perception and plays the part of a censor to a 
certain extent. In addition, it is partly conscious and partly uncon- 
scious. (3) The super-ego which rules the ego. Its chief function is 
criticism, which creates in the ego an unconscious sense of guilt. It is 
partly instinctive and partly influenced by prohibitions through 

It is unnecessary at this point to delve into the various methods ap- 
plied in Freudian analysis. There are, however, several more concepts 
directly involved in analysis that should be introduced, namely, repres- 
sion, sublimation and symbolization. These are only 3 of the 17 
"mechanisms" which Freud proposes and which Healy calls "dyna- 
misms." They may be viewed as "mechanisms" by which the organism 
in its strivings frees itself from annoying situations. These concepts of 
organized tendencies of reaction do not involve the assumption of some 
dynamic force, but are descriptive of the way in which the ego and super- 
ego operate in relation to the id. Repression consists of thwarting 
the normal mode of activity. This may be accomplished in at least two 


different ways. The normal person directs, shunts, or inhibits the 
urge or striving which is incompatible to his ego or super-ego, into a 
mode of action that is compatible. The neurotic individual is not suc- 
cessful in redirecting this urge; he represses it. It is relegated to the 
unconscious or to the id, where it constantly struggles to appear in 
action. Since the ego tendencies have succeeded in repressing it, the 
urge cannot appear in consciousness except in some disguised form. 
The disguises of thwarted urges take the form of dreams and various 
forms of functional disorders. One important characteristic of the 
repressed desire or urge is that it is not consciously recognized or per- 
ceived as such. 

Sublimation is the means by which the libido finds expression in every 
day life. Many of the strivings of the unconscious are not acceptable 
to the ego. There are many perverted sex urges; if these are repressed 
and no neurotic condition follows, a sublimation must take place. One 
of the classic examples of sublimation centers in the sadistic tend- 
ency of man. This is the tendency to inflict punishment or practice 
cruelty on the object which is loved. A surgeon may be manifesting 
the normal response to this thwarted tendency. That is, he cuts and 
hurts people, but in the reversal of the process he heals them rather 
than hurts them. A man whose impulses would indicate a long list 
of murders and other crimes, by sublimation turns out to be a writer 
of crime and detective stories. Actors and actresses may be supposed 
to have had a strong tendency towards exhibitionism or narcissism. 
Their sex urges are sublimated. 

Symbolization can best be discussed in connection with dreams, 
although many other varieties of activity make use of the same concept. 
Earlier in this chapter latent dream content was said to be different 
from the manifest dream content. Freud views all dreams, with the 
possible exception of the recurring dreams of war neuroses, in which some 
incident or horrible situation was reproduced, as wish fulfillments of a 
sexual nature. During sleep the censor (one of the functions of the 
ego) takes an active part in shaping and distorting the latent dream 
material into acceptable manifest material. The censor is supposedly 
cognizant of the wishes or urges to be fulfilled. Since the latent content 
of the dream is unacceptable to the ego, it comes out in a disguised 
form. In other words, all objects and actions which are set forth in 
dreams are symbolic of or stand for some other object or action of a 
sexual nature. Dreams, according to Freud, may then be interpreted 
on a basis of symbolism. The system of symbolism is not a chance 


arrangement but is inherited in some way by the unconscious mind. 
Because of this inheritance, it is difficult for individuals who are un- 
versed in folk lore to find the sexual connection between the symbol and 
the object that it stands for. Symbolism is also used by the analysts in 
interpreting many inadvertent acts of every day life, such as mispro- 
nunciation of well known words, inability to remember a well known 
address or name and an unusual movement such as putting the wrong 
end of a cork tipped cigarette in the mouth. Although the doctrine of 
fixed symbolism is inherent in the Freudian scheme, the analyst theo- 
retically makes use of the free association method in determining what 
the symbols represent. Fixed symbolism means, of course, that a 
particular word always stands for a particular object and no other 
object. This line of reasoning implies that all individuals have the 
same or nearly the same experiences and consequently have the same 
associations. Unquestionably there is a certain community of experi- 
ence. One has only to ask different individuals what word they asso- 
ciate with grass, knife, table, black, et cetera to discover that many of 
the responses will be identical. Kent and Rosanoff have made use of 
this community of association in establishing an association test for 
detecting neurotic individuals. Freud's notion, however, does not 
conform to the usual ideas on association and symbolism. All of the 
words which he wishes to consider are symbolic of sex. It might be 
expected, then, that all objects resembling the sex organs in shape or in 
function stand for these objects. This is similar to the practice of 
magic among primitive people, who believe that injury of an enemy can 
be accomplished by transfixing with an arrow an image of the enemy. 
All elongated objects, trees, poles, sharp weapons, umbrellas signify 
the male element. Groves of trees, boxes, rooms, pockets, fish (because 
of their fecundity, odor, or shape of the mouth) and caskets signify the 
female element; climbing, mounting, going up and down stairs all 
symbolize the sexual act. The symbolization is too extensive to treat 
further in this text, but this brief explanation should tend to make clear 
to the reader the general nature of the scheme. 

An example of a lapse and a dream will convey a somewhat better idea 
of the working of the system. An individual writes a letter which lies 
on his desk for several days; he finally picks it up, puts it in his pocket, 
and mails it two days later. It is returned for lack of postage. Freud 
maintains that this behavior is purposive and that it has some under- 
lying unconscious motive. Likewise the pronunciation of Lohn Jandis 
for John Landis must be occasioned by some mechanism. Perhaps the 


individual had some unpleasant association in which the word John 
figures. The groom who unintentionally fails to keep his wedding 
engagement may be influenced, unconsciously of course, by the fact 
that perhaps this is not the right girl or that he is not inclined toward 

The following dream set forth by Freud (451) brings out clearly how 
symbols may be applied. 4 

Then some one broke into her home and she called in fright for a watchman. But the 
latter had gone companionably into a church with two "beauties." A number of steps led 
up to the church. Behind the church was a hill, and on its crest, a thick forest. The 
watchman was fitted out with a helmet, gorget and a cloak. He had a full brown beard. 
The two were going along peacefully with the watchman, had sack like aprons bound 
around their hips. There was a path from the church to the hill. This was over-grown 
on both sides with grass and underbrush that kept getting thicker and that became a 
regular forest on the crest of the hill. 

The symbols are clearly recognized. The trinity of persons is the 
male genitals; the chapel, hill, and forest, the female genitals. The steps 
signify the sexual act. A good example of the free association method 
as employed by the analysts occurs in the interpretation of a dream 
in which the number 2477 appears. This case was presented by Jung 
(452). In attempting to arrive at the significance of the number, the 
patient thought of the birthdays of himself, his wife, his mistress, his 
mother and his two children. He was born on the 26th day of Feb- 
ruary. February is the second month and occupies the units place. 
Therefore the number may be written 262. 

He was born 26 
His mistress was born 28 
His wife was born i 
His mother was born 26 
His children were born 29 




Unfortunately, when these numbers are totalled, they do not produce 
the desired result. In addition, the patient was 36 years old at the time 
of his analysis, and his mistress was 25. The addition of 61 still does 
not furnish the correct total; consequently by further associations the 
patient recalls that he was born in February 1875 and his mistress 
was born in August 1885. If these are converted into a number in a 
slightly different manner, the numbers 275 and 885 are secured. It 

4 Reprinted by permission from S. Freud, A General Introduction to Psychoanalysis. 
Liveright Publishing Corp. 


should be pointed out that the number representing the month now 
occupies the hundreds place, and the first two figures of the year are 
dropped. When all of the numbers thus obtained by these devious 
associations and manipulations are added, the sum is 2477. J un g> f 
course, assumes that these calculations and manipulations were made 
in the unconscious. 

The authors recognize that many psychoanalysts would not sub- 
scribe to Jung's theoretical explanation of this dream. The choice of 
this illustration is perhaps unfair to the workers in the field, but it. 
demonstrates rather clearly certain difficulties which are encountered 
in accepting such theories without critical evaluation. 

The earlier psychological theories of Alfred Adler (453) are set forth 
in a volume entitled Studie uber die Minderwertigkeit von Organen. 
This was translated later and appeared under the title of Organ Inferi- 
ority and its Psychical Compensation. In the course of his clinical ex- 
perience, certain of his concepts were changed, and emphasis was placed 
upon different phases of his theories. The changes in his point of view 
are brought out in his books, The Neurotic Constitution and Problems of 
Neurosis. Although Adler was one of Freud's early disciples, he soon 
formed the opinion that Freud was placing too much emphasis on the 
strivings of the libido. He insisted that there were other fundamental 
facts, and one in particular that underlies all neurotic behavior as well 
as much normal behavior. This fundamental fact or feeling was that 
of inferiority. There is an attempt to overcome this feeling of inferiority 
by a fundamental urge towards dominance or superiority. The concepts 
which Adler recognizes, then, in his Individual Psychology are a feeling 
of inferiority and a universal will to power. These feelings may center 
in an actual "organic inferiority" such as poor vision, deprivation 
of a limb, poor development of the lungs, deficiencies of sexual devel- 
opment, and deficiencies of metabolism, abnormalities of the viscera or a 
host of other morphological inferiorities which cannot be detected 
readily. Adler noticed that psychical compensations occurred for these 
organic deficiencies, just as in organic functioning, compensation takes 
place. For example, the functions of a misplaced or undeveloped kidney 
are taken over to a large extent by the normal kidney. In renal disease, 
the heart may be called upon to perform extra duty because of the dis- 
eased member. This "will to overcome difficulty" or inferiority may 
result in different types of activity. On the one hand, an individual 
may compensate by directing his energies toward overcoming the spe- 
cific difficulty such as a one armed man may do in becoming a good 


tennis player. Another example of this type of compensation was 
exhibited by Demosthenes in overcoming an actual speech difficulty. 
On the other hand, the compensation may take place in exerting supe- 
riority along a different channel. Byron, who had a club foot, became 
a great poet. Likewise, the undersized individual may compensate by 
becoming an intellectual leader. In the case of neurotics, frustration 
of the normal cravings for superiority happens. They are unable to 
develop an adequate outlet. The phantasies of the individual are 
attempts to escape from the demands of the environment and arrive 
at a feeling of superiority. A man who is effeminate in stature and 
appearance may compensate for this lack of physical masculinity by 
developing a deep voice which is one of the attributes of a large man ; 
hence he becomes superior by this means. The neurotic adopts various 
ways of compensating, but it must be kept in mind that these compensa- 
tions are for self-enhancement. A very good account of the various 
ways of compensating is given by Fisher (454). The following list 
will furnish a fairly good idea of the varieties of compensation although 
it is by no means complete. 

1. Over-evaluation of a physical or mental trait. 

2. Vicarious compensation; identifying oneself with a superior person or organization. 

3. Belittling others. 

4. Blaming others for one's own failures. 

5. Belittling oneself. 

6. Religious compensation. 

7. Day dreaming (autistic thinking) 

8. Anti-social actions. 

9. Becoming ill. 

The work of Farnsworth was discussed previously. He found that 
organic deficiency (visual and auditory) did not result in overcompensa- 
tion. The most extensive attack on Adler's theory is the work by Acker- 
son (455). He tried to show the relation between certain physiological 
conditions which might cause inferiority and the actual appearance of 
inferiority as designated in clinical case records of juvenile delinquents. 
Undernourishment or undersized condition, history of encephalitis, 
lues, convulsions, mental deficiency, speech defects other than stuttering 
yielded coefficients of correlation with the presence of clinically noted 
inferiority of very low order. Practically all of the coefficients were 
below .30. He also presents data that enable us to determine whether 
the clinically designated cases of inferiority tend to exhibit certain types 
of suggested compensatory behavior to a great extent. Behavior such 


as stubbornness, lying, fighting, secretiveness, quarrelsomeness, boast- 
fulness, bashfulness, and day dreaming was correlated with the clinical 
diagnosis of inferiority. On the whole these correlations were low, rang- 
ing from about .20 to .50. These data seem to indicate that social 
factors rather than physiological factors are predominant in the control 
of behavior patterns. 

Thus far, Adler has postulated only a general striving to superiority. 
This striving does, however, call for the postulation of an unconscious 
mind. When these strivings are thwarted, the individual becomes self 
critical and consequently develops a feeling of inferiority. Adler (456) 
says in relation to this point: 

Yet neither the inherited organism nor the environment is wholly responsible for the 
sense of impotence; nor is it cured by both together. The degree to which it is felt is due 
to both these factors plus the reaction of the child. As a conscious relation between its 
organism and environment, the child's pysche seems to have an indefinite causal power. 

The standards of criticism are self estimate or estimates of others. 
Adler makes environmental influences especially potent in determining 
the directional trends of the superiority lure. These are organized early 
in the life of the child. The immediate family influences determine to a 
considerable extent what the child will expect in life and the form of 
compensation which will arise as a result of feeling inferior in one way 
or another. The order of birth in the family is, along with many other 
factors, influential in establishing trends. Whether a child happens to 
be the first born, one of a number, or the last born, is an important 
consideration. The way these children are treated and their subsequent 
reactions to life will be markedly different. 

How does Adler dispose of the Oedipus complex? He does not deny 
that sex impulses are important, but he does maintain that the erotic 
life can be explained only when the directional trend of the individual's 
life is understood in relation to the environmental factors that have 
helped to shape it. The Oedipus complex is nothing more than the 
desire for power or superiority. The father is the head of the family, 
the ruler, the possessor of power. The son is under him; he would 
depose the father and possess the mother. The child is not seeking the 
mother in a sexual way but the power which the father possesses. 
Dreams are utilized in this system to indicate the directional trends of 
the individual and are not the fulfillment of wishes. They reveal the 
fundamental attitudes of the individual towards unsettled problems 
of life. 


The other name usually identified with psychoanalysis is that of 
Jung, who is best known for the introduction of psychological types. 
Jung's (457) system is not essentially different from that of Freud. In 
fact, Freud seems to have modified his concepts to include certain 
factors which Jung insisted must exist. The emphasis placed on the 
sex urge by Freud is only one of many collateral urges according to 
Jung. The libido is now the source of all energy and not strictly 
sexual energy. It contains the primal urge to live, and as the sex urge 
develops, it is the source of its energy. The difference in the concepts 
is that Freud postulates primarily one urge, whereas Jung postulates 
several, arising from one great storehouse. 

In regard to the unconscious, Freud and Jung are in agreement, 
except that Jung attributes more characteristics to it. The unconscious 
contains, in addition to repressed material (the personal unconscious), 
the residue of animal ancestry. The unconscious inherits, by means of 
structural disposition, racial and social habits. This system of inher- 
ited racial and social habits is designated the "collective unconscious/'' 
The dispositions and residual habits are "primordial ideas" or "arche- 
types." Jung offers, in proof of the inheritance of these tendencies, 
examples of myths and folk lore which universally arise. Numerous 
insane patients produce bizarre symbols and stories, which could not 
be produced unless there is some inherited mechanism for retaining 
them. Dreams are useful in Jung's scheme only in so far as they are 
directed toward solving some problem in the future. They are uncon- 
scious energy manifestations of the individual's attempt to solve a 
problem in the future, in contrast with the Freudian point of view that 
they are the urge of the libido to bring into expression the reaction to a 
situation in the past. 

One factor which has not been discussed is that of psychological types. 
The course of the libido is further complicated by the inheritance of 
temperament types. In the beginning stages, the libido and other im- 
pulsive tendencies are capable of being modified by the temperament 
type. Jung recognized two major types, the introvert and extrovert. 
These major types resulted from his attempt to reconcile Freud's 
libido with the concepts of Adler. In this scheme Jung retained his own 
concept of a general energy, but said that in those individuals who 
were motivated by "will to power" and "feeling of inferiority," the 
libido must be directed inward toward themselves. The concept of the 
fixation of the libido on external love objects gave rise to the notion of 
movement outward or the movement away from the self, which is 


typical of the extrovert. This is analogous to the stages of sex develop- 
ment in the child, who is first autosexual, and later homosexual or 
heterosexual. The terms introvert and extrovert have intrigued many 
psychologists but have very little psychological significance. 

There are many variations of the three systems of psychoanalysis. 
The variations are not so important from a theory angle as they are 
from the approach to psychotherapy. It is impossible to discuss all 
of the variants and the student is referred to the work of Nicole (458), 
Alexander and French (459), Horney (460) (461), Fenichel (462), Reik 
(463, 464, 465, 466), Rank (467, 468, 469), Deutsch (470), and Rogers 
(471), for detailed elaboration of many of the systems. We shall pre- 
sent briefly the theories of Rank, Reik, and Horney. 

Rank has espoused a diversified point of view with regard to his 
theoretical basis of psychoanalysis. In his early years he was a rather 
orthodox Freudian. Later he attached great significance to the birth 
trauma as the motivating influence in personality dynamics. He main- 
tained that the physiological and psychic shock of birth produces a 
modification of the individual's characteristics. The individual reacts 
to life situations, especially those involving separation of any kind, in 
terms of the reaction to the original birth situation. The individual 
never overcomes his" feeling of insecurity, helplessness, isolation, anxiety 
and pain. His future life is one of attempting to regain the prenatal 
bliss, security and protection which was experienced in the uterine 
situation. Life situations tend to furnish a unique set of experiences 
for each individual and the interplay of these with his reaction to the 
birth trauma mold the general characteristics of the individual. The 
attachment to the mother after birth affords a partial sense of security. 
This is later broken down through weaning, habit training, etc. Primal 
fear of facing life and separation is reestablished through each succes- 
sive stage of attachment and the breaking of these attachments. Gain- 
ing of life goals, only to see them disrupted by circumstances and 
finally the loss of attainment through prospective death, maintain a 
continuous focus on the antagonistic elements of security and depriva- 
tion of security. The role of the individual changes after birth from 
that of being created, to that of creating. He begins to do for himself 
as well as to his environment. He develops the power and volition to 
in part determine his own fate. External forces of authority and 
morality are incorporated into his own personality and furnish addi- 
tional impulses to his basic instinctive forces. Idealism is one of the 
outgrowths of these processes. Ideals developed are determined in a 


large measure by the culture into which the individual is born, but the 
ideals are influenced in turn by the individual's needs and attitudes. 
It is the influence of the cultural system that has played a large role in 
the later thinking of the followers of the Rankian theories. Volition 
or will is perhaps the most vital force in integration and disintegration. 
There are three phases in the development of the will. In the first 
phase there is an incorporation of forces such as sex drives, assertive 
impulses, parental authority, and moral codes into the self. At this 
stage the individual recognizes that he is different but still derives some 
security through feeling of belonging or being like the group. In the 
second phase, the will is felt as counter-will. The outside forces are 
not incorporated and antagonism develops between the will and counter 
will. If the conflict is resolved in favor of the will, better integration 
and development occurs; if not, disintegration takes place. He de- 
velops guilt feelings and makes unhealthy attempts to rationalize and 
deny his will. In the third phase, he develops a "conscience" and a 
personality structure unique unto him. Personality then stems from 
his own creative experience and constructive and ethical considerations. 

The ego for Rank is a combination of impulse, drives, emotions, and 
conscious components of will. The impulses are instinctive strivings 
which may very often be sexual. The super-ego is developed somewhat 
along the same plan as the Freudian super-ego. The id or libido is the 
basic drive which impels the individual to activity. 

The dynamisms have been given somewhat different meaning from 
those of the Freudian system. When will is expressed as counter-will 
(undesirable) the individual develops guilt feelings and attempts to 
justify the counter-will. If the counter-will is expressed against the 
moral code as represented by the parents, we have either the Oedipus or 
Electra complex. Guilt, however, is aroused by the expression of the 
counter-will rather than through the prohibited incest relationship. 
Creative drive is not the Freudian libido but rather the regulating force 
of the libido by the will. Recognition of willfulness affords individuality 
which emphasizes feelings of inferiority and insecurity; this is avoided 
by repression. Repression may protect the individual against life, and 
hence facilitate the return to bliss and security. Regression comes about 
because willing and assertiveness are in themselves painful. In order 
to avoid such pain the individual thinks of the past which is less vivid 
and less frought with insecurity. Identification is the attempt to attach 
the will to others, thus gaining commonality and security. 

Reik's viewpoint is essentially Freudian although he broke with 


Freud in a number of respects with regard to detail. He recognized the 
importance of instincts as determinants of behavior but felt that all of 
the biological needs of the organism were important in appraising the 
end result. He might be recognized as the precursor of some of the 
theorists in the field of extra-sensory perception. He held that the 
unconscious is capable of receiving stimuli from outside sources, and 
discusses the possibility that sense modalities may have been lost in the 
process of evolution. The archaic remnants of these senses may, how- 
ever, be partially retained in the unconscious which accounts for im- 
pressions and hunches on which the individual may act. Similarly, he 
holds that ancestral experiences may be partly retained through in- 
heritance in the unconscious. Unconsciously perceived stimuli produce 
effects in shaping personality and behavior. In one respect he seems to 
have followed an early lead of Freud. Freud, according to Fenichel, 
classified instincts into two major categories: "sexual instincts" and 
"ego instincts". The "sexual instincts" were essentially sexual wishes. 
Anxieties, guilt feelings, and ethical or esthetic ideals which fought 
the sexual wishes were called "ego instincts." Reik seems to subscribe 
in part to this formulation when he speaks of ego drives. He distinguishes 
between love and sex, calling sex a biological need like hunger and thirst. 
Love, on the contrary is not primarily biologically determined but 
psychically determined. The ego drives are those which protect and 
preserve existence. The sex drive and the ego drives become blended 
and one rarely sees the sex drive operating alone. The ego drives can 
cause disturbances if left unsatisfied in the same manner as the sex 
drive. Developing out of the ego drives and the environment, Reik set 
forth the ego-ideal. It is a replica of parents, teachers, and figures of 
authority. The ideal may be compared to the term "aspiration level". 
The individual never attains completely his ego-ideal and recognizes his 
deficiencies. This is similar in certain respects to the superiority- 
inferiority concept of Adler. The more nearly one reaches the ego- 
ideal, the less conflict and hence the better the adjustment. The 
major constructs of the Freudian system are accepted, i.e., the id, ego, 
and super-ego, although slightly different functions are assigned to each. 
He disagrees with Rank on the importance of the birth trauma. He 
parts from Freud in believing that the new born child is narcissistic. 
He believes that narcissism is a later and secondary development. Self 
love is learned through love of parents and other contacts and when 
deprived of love, narcissism becomes the desire to be loved. The Oedipus 
complex is only a stage of development and does not remain in the un- 
conscious as a motivating force throughout adult life. Reik does not 


regard sexual disturbances as the sole basis for neurosis. Neurosis 
results from the emotional disturbance produced by loss of self-trust 
and self-confidence, which in turn set up anxieties and inhibitions. 
These reflect failure to achieve two ego ideals, to love and to achieve. 

The modern trends in psychoanalysis, as exemplified by the writings of 
French and Horney, seem to close the circle which Adolph Myer con- 
structed. He maintained that the inherited structure and tendencies, 
the life experiences (developmental processes), and the stresses of the 
environment all had to be evaluated and studied if one expects to under- 
stand the genesis of a particular disorder. Various aspects of the parts 
of the circle have been emphasized by the analysts, particularly the 
instinctive tendencies and the developmental processes. Horney has, 
however, recently emphasized the environmental stresses and adjust- 
ment to them, thus giving chief weight to a sociological point of view. 
While recognizing the instinctual drives in shaping behavior, attention 
is given to environmental and interpersonal relations in shaping per- 
sonality. Ways of adjustment to present difficulties are of greater 
importance than past traumatic experiences. In this respect certain of 
Rank's ideas seem to prevail and it is in part the point of view held by 
Rogers and his followers. Thorpe and Katz (472) have stated the point 
of view very succinctly and we present their interpretation in the follow- 
ing quotation 5 

"When the Freudian pleasure principle (of the libido) theory is for- 
saken, the individual's striving for various forms of security assumes 
more importance, and the role of anxiety in such striving appears in a 
new light. The principal factor in the development of a psychoneurosis 
is then neither the Oedipus complex nor any other kind of infantile 
pleasure-striving; it is rather those adverse influences which make 
the child feel rejected, defenseless, and afraid of the world. When 
dangers threaten the child, he develops certain 'neurotic trends' which 
enable him to cope with the environment in the light of his own needs. 
'Narcissistic, masochistic, perfectionistic, trends seen in this light are 
not derivatives of instinctual forces, but represent primarily an indi- 
vidual's attempt to find paths through a wilderness full of unknown 
dangers.' The anxiety element in neurosis is then not the expression of 
the 'ego's' fear of being overwhelmed by instinctual drives or of being 
punished by a hypothetical 'super-ego', but is a result of the failure of 
certain safety devices (psychological mechanisms). 

A psychoneurotic disorder may thus be defined as a particular kind 

6 Thorpe and Katz. Reprinted by permission from The Psychology of Abnormal Be- 
havior, Ronald Press Co., N. Y., 1948. 


of struggle under difficult conditions (for the ego) of life. It is associ- 
ated with disturbances in relations between the self and others and to 
conflicts arising from such maladjustments. This concept of the psy- 
choneuroses changes the whole approach to psychoanalytical therapy. 
The therapist does not enable the patient to gain mastery over his 
instincts, but helps him to reduce his anxiety to such a degree that he can 
dispense with his neurotic symptoms because his possibilities for satis- 
faction are limited by them." 

The psychoanalytic theories have been attacked by many writers. 
Among the antagonists may be listed Dunlap, Woodworth, Jastrow, 
Hollingworth, Wohlgemuth and Robinson. 6 The various concepts 
which the analysts have erected have been subjected to criticism on a 
basis of the mystical assumptions underlying the concepts. The tri- 
partite division of mental life or the psyche into conscious, pre-conscious, 
and unconscious cannot be sustained on any logical basis. The assump- 
tion that knowledge may be conscious and unconscious at the same time 
is untenable for any system of psychology, but even if this assumption 
were allowed, there seems to be no neural or physiological basis for 
understanding the interplay between these parts of the psyche. More- 
over, there is so much inconsistency in the functions of these two aspects 
of mental life that it is impossible to be certain what is meant by the 

The fundamental "urge" itself is not agreed upon by the various 
analysts. Freud started by postulating one urge which he called the 
libido. This concept had to be augmented by the postulation of the 
"eros" (life instinct) and the "death instinct." Adler maintained 
that there was one urge but described it as "striving forward" or "will 
to power." Jung postulates several collateral urges which are compli- 
cated by his inherited "temperament types." Since the dynamics of 
the id and its strivings are so fundamental to the whole system, it might 
reasonably be expected that there would be some agreement among the 
proponents of the system. What they seem to say is, that there is a 
tendency for the organism to be active, but why it is active and what 
directs its course of action is still enshrouded in mysticism. 

On the one hand, the conscious, preconscious, and unconscious 
mental life of the individual seems to be inextricably tied up with physio- 

6 Their respective objections have been amplified in the following books: Dunlap, 
Mysticism, Freudianism and Scientific Psychology; Woodworth, Contemporary Schools of 
Psychology; Hollingworth, Abnormal Psychology; Jastrow, 'The House that Freud Built; 
Wohlgemuth, A Critical Examination of Psychoanalysis; and Robinson, Wish Hunting 
in the Unconscious. 


logical states; on the other hand, the postulation of a tripartite mind dis- 
embodied and conscious "stuff" seems to be the basis of all mental life. 
If the first point of view is accepted, then desires might reasonably be 
conceived as the motivating influence of the individual, but the analysts 
attribute to their "motives," capabilities and persistency of function 
far beyond any thing that can be proved by experimental psychology 
regarding desires. If the second point of view is examined, a greater 
conflict with psychological principles and even the tenets of ordinary 
common sense is apparent. No one seriously maintains that there is a 
mind without a body or that there are "images" that can be moved about 
and stored similar to boxes or objects in a warehouse. 

Another inconsistency in the structure of Freudian psychology is 
related to the mechanism of repression It was pointed out earlier 
that the term "censor" was applied to the force or dynamism by which 
undesirable unconscious strivings were repressed or were altered in 
accordance with the "wishes" of the ego and super-ego. The source 
of the censor's power and dominance seems to be one of considerable 
moment; nevertheless the authors of this theory ultimately fall back on 
some innate tendency. The organization of this innate tendency is very 
interesting since it seems to perform the dual function of preventing 
certain urges from coming into expression at one moment and then seems 
to about-face and abet these same urges by supplying them with dis- 
guises so that they can elude the censor. One may inquire why, if the 
censor supplies the disguises, as it seems to do in manifest dream con- 
tent, it is unable to recognize them at another time. It appears to have 
the faculty of performing its duties (which are determined in accordance 
with environmental and innate influences) in more or less of a voluntary 
fashion. In spite of the fact that unconscious strivings are the most 
powerful motives in man's activities, the censor manages to suppress 
these when necessary or expedient. The source of the censor's more 
powerful tendencies is still obscure. 

The remainder of the criticisms are directed at the procedure in analy- 
sis. The Freudians theoretically use the free association method in 
arriving at the source of a complex. Free association means, of course, 
association that is not directed or influenced by statements or precon- 
ceived ideas on the part of the patient that would direct his line of 
association. Most people already have a preconceived idea concerning 
psychoanalysis; whether their ideas are correct or incorrect matters 
little. If they have a notion that sex topics are of paramount interest 
to the analyst (and most people have this idea) their associations will be 
of a sexual nature. Even if they did not have the idea already firmly 


fixed, the general nature of the instructions in the course of the analysis 
would inevitably lead them into sexual channels, since they must reveal 
any association, however trivial, embarrassing, or disgusting. In 
addition, the point at which the associations are terminated is not made 
clear. If reference be made to the significance of the case of Jung's in 
which the number 2477 was interpreted in light of the association 
method, several pertinent objections may arise. The associations were 
not stopped until the total of 2477 was obtained. The individual could 
have given other associations if asked for them. He could have thought 
of his father's birthday, his aunt's birthday, and even other birthdays 
but they would have been insignificant since they would have influenced 
the total adversely. The conclusion must be reached that the associa- 
tion is stopped in accordance with some preconceived notion of the 

The use of the association method in the manner already described 
should be sufficient to cast grave doubts on the validity of the technique. 

The logical fallacy which the psychoanalysts commit and which will 
be set forth is, however, perhaps the greater error. In practical analysis 
the analysts maintain that if an individual associates the items A, B, C, 
D, and E, in the order listed, E is responsible for the individual's think- 
ing of A originally. A slip of the tongue which was recently heard may 
make the situation clearer. An elderly lady, in referring to her youngest 
son (one of four children), called him her last sin. Some one remarked 
that the slip could be interpreted in a very embarrassing way. The 
lady in question replied that she was quite willing to admit that the 
youngest child was unwanted and was conceived at an undesirable time. 
An analyst would say that the slip was caused by the unconscious wish 
not to have had the son or even by the unconscious wish to have had the 
son by another father. The interpretation is not pertinent for our dis- 
cussion. The thought of the son as unwanted must, according to the 
analysts, be responsible for the pronunciation of son as sin. 

The interpretation of symbols has been partially discussed earlier in 
this chapter. If the neurotic patient admits that an unusual figure 
such as , which he or she employs in writing, is a symbol of union of 
the two sexes, the admission must be made by any one that the inter- 
pretation is correct. On the contrary, if the same figure is employed by 
another individual, the assumption cannot be made that it is a symbol 
of sexual union unless the admission is made. It may be symbolic of 
some mathematical formula. Symbolization is an individual matter, 
except in so far as many people are subjected to the same environmental 


influences and have almost the same experiences. The American flag 
is symbolic of the same things for many people of this country; yet even 
in this country the things for which it stands may be different for the 
prohibitionist and anti-prohibitionist. The American flag has an en- 
tirely different meaning for a Chinaman from its significance for a citizen 
of the United States. The fixed symbols of the Freudians have a still 
greater range of associations. A woods may be symbolic of fear for 
the youngster who has been lost at some time. For another child, the 
woods may be a pleasant place to spend an afternoon in play; yet the 
analysts do not hesitate to say that a wood in a dream stands for the 
pubic hair. 

The authors were once present in a group of psychiatrists, several of 
whom were adherents of the psychoanalytic school. At this gathering a 
college student was hypnotized and told that while he was asleep he 
would have a dream. He related the following dream when awakened. 
"I was riding down a wide street on a bicycle, holding on to the back of 
a stone truck." The analysts attempted to learn the meaning of the 
dream by asking a variety of questions, including such questions as 
these: (i) Did you like your father or mother best? (2) Do you feel 
people are fair to you? (3) What does a truck signify to you? The 
student answered the questions as intelligently as possible, and although 
the dream was not interpreted, it might readily have been in accordance 
with Freudian principles. Another member of the group (non-analyst) 
asked a question which the student could answer and which to the 
writers was adequate for explaining the dream. The question asked 
was, "Can you remember anything that might have caused the dream?" 
The answer was illuminating. When about 8 years of age, the subject 
had ridden behind a stone truck on a bicycle, had been thrown off, and 
had had concussion of the brain. The dream appears to be a simple 
reproduction of an actual incident; however, if interpreted in terms of 
fixed symbolism, it would have an entirely different meaning. 

Sears (473) discusses also many of the other psychoanalytic concepts 
and relates the known facts to the concepts. The material presented 
is sufficient for the purpose of this text. We should like to quote a 
paragraph from the conclusions drawn by him: 

"The experiments and observations examined in this report stand 
testimony that few investigators feel free to accept Freud's statements 
at face value. The reason lies in the same factor that makes psy- 
choanalysis a bad science its method. Psychoanalysis relies upon 
techniques that do not admit of the repetition of observation, that 


have no self-evident or denotative validity, and that are tinctured to 
an unknown degree with the observer's own suggestions. These 
difficulties may not seriously interfere with therapy, but when the 
method is used for uncovering psychological facts that are required 
to have objective validity it simply fails. " 

In order to recapitulate some the the various theories and to show 
how the dynamics would be worked out, an actual case of psycho- 
neurosis is presented for discussion, formulation and therapy from 
different orientations. 7 To that end we wish to compare here the theo- 
ries, possible formulations and attack on the same problem by the 
Adlerian and Jungian schools of psychology, the psychoanalytic approach 
of the Freudian school and finally the psychobiologic orientation originat- 
ing with Adolph Mayer. 

In a section necessarily as brief as this and covering, in a sense, the 
whole scope of all of these fields it is almost inevitable that, due to 
material condensation, repercussions might be heard from the adherents 
of these respective groups. Protest, argument and defense of their 
systems of thought and therapy will be raised. Though aware of the 
likelihood of protestations from various sources, it is felt that in general 
the approaches to be described are fairly representative of the schools. 


The patient is a 39 year old, white, single male. He has been unable to work or to 
make an adjustment to life since his discharge from military service, after a year's service 
because of medical reason. He has been hospitalized for 18 months in two hospitals. 
The presenting symptoms some months ago on his present hospital admission were de- 
pression, suicidal thoughts, and numerous physical complaints. 

Descriptively, Joseph is a large person well over 200 pounds, brawny and "rough 
looking". However, he gives the impression of being an overgrown boy, of putting on 
an air of bravado to hide inner panic. He was quite demanding of attention on admission, 
and very insistent on wanting to be helped. He would constantly ask the ward physician 
the meaning of innumerable phantasies and dreams. Joseph's ancestors are first gener- 
ation from a small European country. He is Roman Catholic by religion. Joseph, the 
senior, now dead, was described as a huge hulk of a man, a hard worker and a hard drinker. 
Apparently the father was an adequate provider according to the standards of the family's 
environment, a seaport city of the West Coast. The father at one time was in charge of 
the hiring of stevedores and ruled with an iron hand. His first wife had six children before 
her death. The oldest was a boy, named after his father. Then in succession came five 
sisters. The patient's mother married in the face of the responsibility of six children and 
in turn began to bear children. There were five more children of whom Joseph was the 

7 This section has been prepared by James M. Rankin, M. D., Chief, Continued Treat- 
ment Service, Neuropsychiatric Hospital, Veterans Administration Center, Los Angeles, 


second in line, following a second boy 2 years older than he. After 2 more sisters, a younger 
brother was born. It appears that when father was sober he was a quiet considerate man 
who was kind to the children. A very vivid picture is given of father when drunk. He 
became noisy, nasty, aggressive and destructive. He would roar into the house and the 
children scattered like frightened quail. Joseph's place of security was under the sink. 
There appears to have been some real danger in confronting this drunken person. Mother 
would be sarcastic, hostile and belittling when father was sober and lead him to the Priest 
to take vows of abstinence, all to no avail. She seemed to be fascinated by death, at- 
tending wakes for miles around and forcing the children to accompany her. She is de- 
scribed as a hard, cold, rejecting person whose emotional life was transferred to the church. 
Early in life, constipation appeared in the patient, necessitating enemata by the mother, a 
procedure followed for years. Joseph's childhood was a rough and tumble existence with 
other children of the neighborhood. His education was a strict authoritative type in a 
parochial school. At an early age, there appeared to be developing a definite hostility 
toward his sisters and feelings of rivalry toward the next older brother. He was a good 
student and seemed to have ambitions toward a complete education. Unfortunately 
while the patient was in first year high school, the father made unwise investments and lost 
his savings. Thus Joseph resentfully found it necessary to go to work. The history in- 
dicates that he apparently had a stable work record, being with a large firm for about a 
dozen years. During his early twenties there was the not unusual behavior of drinking, 
parties and sexual adventure. The oldest of the siblings eventually died of tuberculosis 
and mental disease, a shock to Joseph. Ultimately, Joseph acquired gonorrhea; this was a 
tremendously fear-invoking and shameful event. Soon after, he acquired pneumonia 
necessitating a prolonged convalescence. Events show that he quit his job, drank ex- 
cessively and depended on political patronage for work. Because of tension, shakiness and 
sensations of throat constriction, he was subjected to a thyroid operation with little sub- 
sequent relief. His work record increasingly deteriorated to the point of his being in a low 
economic scale. His physical and emotional complaints increased in frequency to the 
point that there was some question of accepting him into the service during the war. 
Actually he soon was hospitalized after induction but was returned to duty. Within a 
year however, it was necessary to discharge him for nervousness and he received a govern- 
ment pension. Since then he has been a restless wanderer from city to city trying un- 
successfully to hold a job. Increasingly he began to have headaches, noise sensitivity, 
constriction in throat and chest, weakness and shakiness. He became preoccupied with 
fears of disease especially tuberculosis and epilepsy. Religion preoccupied him with 
much ambivalence from ecstasy in fantasies to intellectual defiance and hostility to the 
church. His depression and apathy were marked, but at variance with his aggressive 
demands of hospital personnel for psychiatric aid. This aggressive demanding increased 
with an exacerbation of all his fears and symptoms when his pension was cut off. Physical 
examinations were entirely negative, as were various laboratory examinations, such as the 
electroencephalogram, basal metabolism and blood tests. Because of his psychiatric 
picture containing many varied neurotic classifications, his diagnosis was made, i.e., 
psychoneurosis, mixed type. Of major import was his phobic reaction, fear of disease 
and death, death paradoxically at times thought of in suicidal terms. Because of his 
inability to get rid of these recurring bad thoughts, and of his preoccupation with geo- 
metric designs and repetitious fantasies and ambivalent attitudes, he reveals much of an 
of an obsessive compulsive nature. These things, plus frequent periods of marked anxiety 
and depressive reactions, all show the mixture of syndromes so often found in the severe 



To understand the approach of the Adlerian school it is advisable to 
review briefly some of their concepts. Their psychologic philosophy is 
based on the doctrine of "unity of the personality"; a preliminary to 
this is the secondary doctrine that states in substance that the social 
attitude and reaction of the child is indicative of preparation for sub- 
sequent efforts toward self-sufficiency and supremacy. Thus the con- 
flict is between the strivings of the person, the organism, and society. 
In this there is the effort at preserving the unity of the organism in 
compromise with social demands. These doctrines are based on the 
earlier Adlerian concept of organ inferiority. He postulated that the 
child develops a conscious awareness of organ inferiority that to varying 
degree is carried into adult life. In addition he felt that the various 
body organs either through heredity, structural defect or disease made 
its inferiority consciously felt in the psyche. This conscious awareness 
of the organ inferiority stimulated in turn an impulse to compensate for 
the defect in various ways. Dr. Adler felt that this impulse to com- 
pensate stemmed from a "will to power". Generally stated, there are 
two main goals of the personality, one of social adaptation and service 
to society and the other to the attainment of power. This school feels, 
then, that the neuroses stem from a conflict over the feelings of inferior- 
ity and the urge to power. Secondly, the inability to meet normal 
social demands, stemming from consciousness of a lack of social equality 
and inability to adapt to change, leads to seeking justification in neurotic 
acts. These are defenses against consciousness of inferiority. 

The Adlerian approach then in view of the orientation just outlined 
would be somewhat in this manner. In the conferences with the patient, 
an attempt would be made to determine what the "life pattern" of the 
neurotic is, what is his goal in life? An effort would be made to find 
what he is running away from and what he seeks in his neurotic pattern. 
With these things ascertained, an appeal to his enlightened intelligence 
would be made with the view of bringing about withdrawal of the 
"dishonest" pathologic methods of acquiring power. 

In the case previously sketched the formulation might be somewhat 
as follows: We have a case in which Joseph's father had a central nervous 
system injured by alcohol. In Joseph there is the inherited alcoholic 
tainted, or inferior nervous system. This nervous system inter-connects 
the various organs and tends not only to transmit the awareness of 
inferiority from one to the other, but to accentuate the inferiorities. 
In the case of this patient, there were numerous illnesses. As a child, 
and persisting into adulthood, he was constipated, necessitating ene- 


mata by mother. He almost died of pneumonia twice. He was rend- 
ered unconscious by a blow from a baseball bat as a boy. An older 
brother whom he looked up to and respected died in a mental hospital of 
tuberculosis. A younger brother had tuberculosis. Gonorrhea caused 
intense emotional upset and fear. A thyroidectomy caused more in- 
feriority feelings. One sees then a combination and potentiation of 
organ inferiorities building up to a tremendous strength. The urge to 
power as a boy was blunted by a powerful fearsome father, numerous 
older siblings and maternal "masculine protest". As these series of 
inferiorities made themselves felt his psyche and urge to power were no 
match. The result was neurosis with its conviction of many physical 
ills, the phobias of disease and death and repetitious obsessive throughts. 
From the social aspect we see a person whose father became a social 
outcast with his frequent alcoholic disturbances, arrests and failures in 
pledges of abstinence in church. His older brother died a broken 
man. He in turn developing social inferiority from his environment 
and secondarily from his organ inferiority, felt unable to adapt to 
society's precept. Alcohol became a socially neurotic pattern. The 
war with its greater stress and adaptive necessities was too much. A 
completely pathologic pathway for his urge to superiority was formed. 
After the war he ultimately sought refuge in a hospital for care. What 
then was his probable "life pattern", his ultimate goal? One speculates 
on whether it might not be knowledge, education and culture. Cer- 
tainly early in life he was intensely interested in schooling and libraries 
which he haunted. The urge to power perhaps was to be physically 
dominant like the father. These are speculative. We do not know 
that the neurotic result was the demand for comfort, care and love. 
Possibly then we see the urge to power distorted into compelling society 
to take care of him by the very mechanism of his neurosis. He suc- 
ceeded. However, this success was a Pyrrhic victory. Joseph is un- 
happy, extremely so. Therapy then would be to show him how this 
negative urge to power came about and to approach the ultimate goal 
of a compromise with society. 


Following Jung's break with Freud he began developing divergent 
theories on the framework of psychoanalysis. For example, the Jungian 
postulates an unconscious of two parts, the "personal" unconscious and 
the "collective unconscious", the description of the racial inheritance 
of the psyche. This racial reaction makes itself manifest in day by day 
life and in dreams. This concept of collective unconscious thought, 


considered to be typically Jungian, was mentioned by Freud in his 
writing prior to the separation. The Jungian school does not follow 
the precept of development of infantile sexuality but rather puts more 
stress on the degree of "animus", "anima"; that is the degree of the 
masculine (animus) in woman and the degree of feminine (anima) in 
man. This is derived from the parental constellation in much the 
same manner as in the psychoanalytic theory of the oedipus situation. 
They feel that a neurosis is a conflict of the present and does not neces- 
sarily have its roots in infantile sexuality. Of divergence also is their 
concept that the unconscious is primary and that from it is derived 
inspiration. Here too is found the archetype of the deity, racial thought 
and folklore. Dreams are not wish fulfilling as Freud postulated, but 
represent through archetypes the plans of the patient and the upcoming 
of inspiration. 

A possible Jungian formulation of the presented clinical case follows: 
It would be felt by this school that the sequential order of the siblings 
and their names is of importance in determining the presence of parental 
substitutes. As we know, the first born was a male. The next five 
children in order were females. This sibling order, plus the description 
of the parents, leads one to the concept of a weak father and a strong 
mother. By deduction, it is felt that the father had a mother fixation 
just as the patient does. Joseph has then become the psychologic 
reproduction of his father a femininely oriented figure. Socially he 
shows his unmasculine attitude in his work. He "cannot" work, i.e., 
his neurosis is symptomatic of the feminine in a male body. The 
dependence upon politics in earlier years for work is equivalent to de- 
pending on mother. The Jungian would feel that it is difficult if not 
impossible to make a dynamic construction from this summary because 
of the lack of dream material. In Jungian therapy, great stress is put 
on dreams and their interpretation. Free association and the patient's 
thoughts are not needed. The archetypal symbols are enough to deter- 
mine what is behind the dream in the unconscious. In therapy there 
would be direction given to the patient through discussion of these 
archetypes and much consideration given to the "soul". The Jungian 
therapy is more a "psycho-synthesis" in that the therapist actively 
directs thinking, on a conscious basis, into new channels. 


As in the discussion of the preceding schools of psychology, it will 
be necessary here to mention a few of the psychoanalytic precepts used 


in the case formulation and treatment. It is obviously impossible to 
cover adequately all of the technical working theories of psychoanalysis. 
For this one must turn elsewhere. However, here as in all neurosis, 
there can be seen derivatives of various stages of the development of 
infantile sexuality. If one might loosely make the comparison, the 
development of the personality is akin to the Darwinian theory of 
evolution that is, development from a primitive undifferentiated lower 
scale organism to the highly complicated organism of man. Primitive 
man then would be similar to the early stages of personality develop- 
ment. Psychoanalytically when a neurosis appears the conflict can be 
handled by the ego in many ways, by many mechanisms. One com- 
monly seen mechanism, for example, is that of "regression" of part of 
the total personality retreating to some earlier more primitive era in its 
life span. This "regression" is on a unconscious level, but produces as 
derivatives the many symptoms of neurosis. Analytically the Oedipus 
complex, although only a part of analytic thought, is felt to be critically 
determinative in neurosis. It is demonstrated in this case in only an 
obscure distorted manner. The dynamic formulation of this case might 
be somewhat as follows: Joseph was subject to an alternating changing 
father figure. Without question, the father became a terrorizing primi- 
tive figure. The mother was a cold gloomy woman. She was, with 
little doubt, a sadistic person basically. She could not possibly in 
reality give all the love and attention that the child demanded. Instead 
it got enemata. Analytically, Joseph had no one to "identify" with 
no one to grow up to, to be like, to imitate. He was in fantasy a deserted 
person, alone, who could expect only punishment from the parents. 
His conscience, or "super ego" was a severe one, unconsciously, after 
the parental image of fantasy. Deeply buried in his personality as the 
result of his paternal fears was a passive feminine attitude. This was 
borne out by several actual episodes in his life, which it is not necessary 
to detail here. With little question his flight from a socially and 
economically adjusted life into neurotic regression began with his ve- 
nereal disease. This, to him, was living proof of the punishment which 
his unconscious fantasies, still remaining from childhood, expressed in 
symptom. In appeasement of his unconscious, he began imitating 
father in his alcoholism and social degradation. In service these con- 
flicts were magnified tremendously to the point of marked regression to 
infantile attitudes. Chief of these ultimately was his primitive oral 
attitude of demanding security, care, attention and affection. He got 
these things by being completely passive and helpless as manifest by 


his many symptoms of illness, phobias, weakness and anxieties. His 
depression was from the turning in against himself, punishing himself, 
for hostile destructive unconscious wishes towards his parents. A 
demonstration of the etiology of his headaches, throat constrictions, 
and suicidal depressions was made apparent during an interruption in 
therapy. Due to his emotional attachment to the therapist he was 
apparently symptom-free. Immediately after the interruption, be began 
to have splitting headaches, sore throat and chest pain. He consulted 
many doctors, to no avail. On resumption of therapy, it could be 
shown him through his own associations that this sickness was his own 
self-punishment for the murderous unconscious protests at the doctor's 
deserting him. His symptoms then subsided. Throughout treatment 
he has repeatedly utilized intellectual defense, bizarre fantasies and 
obsessive ruminations as defenses against conscious awareness of his 
primitive oral sadistic strivings for attention at any price, and of the 
turning against himself and passive feminine attitudes. Work had 
always been associated, since the war, with frank panic reaction. Even 
in the early stages of treatment he was unable to do simple hospital 
detail work. Work is unconsciously and regressively associated with 
competition and therefore, a symbol of terrible fantasy punishments. 

Therapy has been and will be long, difficult and uncertain. He is very 
ill, and has at times been very close to the unreality of psychoses. 
Treatment objectives have been the slow gradual process of making him 
aware of the implications of his unconscious hostility and death wishes. 
He gradually, through free association, dream interpretation and utiliza- 
tion of transference phenomena has been able to see the result of his 
hostility. An attempt is being made to uncover gradually these deeply 
unconsicious early primitive fantasies and fears that prevent him from 
attaining a mature personality. As these drives are brought to light 
there is concurrent ego strengthening, a softening of the malignantly 
punishing super-ego, or conscience, and a diversion of the unconscious 
instinctual drives into socially accepted channels. This is the ideal 
aim. In this case, if Joseph can be made happier, his symptoms con- 
trolled, and if he can be gotten back to work, that is an adequate and 
ambitious goal. 


Strictly speaking, this should not be considered a school of thought 
or therapy. The adherents of the Meyer attitude toward psychiatry 


do not wish to feel bound to any preconceived theoretic structure. 
Their attention is closely focused on the medical aspect of the individual. 
In relation to the psychologic a search for disease, disability or defect of 
the body-mind is attempted. The physical aspect then is closely 
watched. As a corollary there is no hesitancy in the use of drugs, 
stimulants, depressants, hypnotics and analgesics as needed in psy- 
chiatric treatment. The psychobiologist has the attitude of examining 
the mind with a body. Similarly, the psychobiologist examines the 
environment, its effect on the organism and the reaction of the per- 
sonality to the environment and society. This is accomplished by a 
meticulous and painstaking life-span history with emphasis on heredity, 
the medical history and the time factor relationship. Essentially the 
endeavor is to look at the individual as a living integer reacting as a 
biologic entity. 

In the case presented, the psychobiologic formulation would start 
with the relationship of the siblings. Here one finds a much older 
brother to whom the patient "looked up". Five sisters followed, some 
of whom acted as nursemaids. Joseph expressed resentment towards 
them, for what specific thing he cannot recall. Of the full brothers 
and sisters the next older was two years his senior. Rivalry is evident 
in the patient's attitude toward him. He consciously resented his 
mother's rejection of him. He felt his parents were unfair to him, even 
to having produced and reared him. The psychobiologist would be 
interested in the childhood constipation, his pneumonia, the later tu- 
berculosis of his oldest half-brother, and his subsequent death. His 
deprivation of higher schooling and reaction to it would be significant 
of feelings of frustration socially. In his third decade of life the in- 
creasing alcoholism and poor work record would be considered as the 
beginning of his defective biologic reaction to society and life in general. 
Further traumatization by gonorrhea and the tremendous physical 
upheaval of thyroid disease and operation set the stage for the final 
coup de grace during the social disturbances of the war. His behavior 
pattern since has been the chronic repetitious symptom complex of the 
sick biologic entity. In treatment it would be necessary to know 
whether his electroencephalogram was normal. Does he have epilepsy 
as he fears? Is his thyroid functioning adequately? Does his chest 
X-ray show tuberculosis? If all his physical tests are normal these 
are used to show Joseph consciously and rationally, that he is not 
physically ill. From another aspect, is he well-endowed mentally? 


What is his intelligence quotient? Actually, we see it is quite high. 
He is very keen mentally. Perhaps with tests like the Murray Thematic 
Apperceptive, for instance, to show attitudes, then by conscious means 
the patient is gradually led to understand there is no physical basis to 
his symptoms and that he is and was resentful of his position in life 
as just one of a large brood of children and of unstable parents. Review 
of the cause and effect patterns of his life helps him to change his biologic 
behavior as a total personality into more realistic and economic patterns. 




In the discussion of the psychoanalytic theories in the preceding 
chapter, the terms motive, urge, drive, instinctive tendency, and innate 
disposition were employed. Each of these terms has a specific meaning 
for various psychologists, although they are used interchangeably in 
much of the current psychological literature. Warren's Dictionary of 
Psychological Terms furnishes the definitions given below for certain of 
the terms. "Motive is a conscious experience or subconscious condition 
which serves as a factor in determining an individual's behavior or social 
conduct in a given situation." "A drive is any intra-organic activity or 
condition which supplies stimulation for a particular type of behavior. 
It covers both organic activating conditions, such as hunger and pre- 
sumably cerebral conditions, such as mental set or such as desire for a 
particular object." "Urge is a strong tendency to perform a certain 
act." Another term which will be employed in the discussion, is desire. 
Desire may be defined temporarily from our point of view as anticipatory 
thinking in conjunction with either localized or non-localized bodily con- 
ditions. Unfortunately, all human action cannot be explained in terms 
of these relatively simple concepts. The problem becomes enormously 
complicated, since life is directed by thought which includes purpose and 
ideals. Feelings, sentiments, moods, and emotions, are other psycho- 
logical concepts which must be fit into their respective places in the 
puzzle; these latter concepts and desires are not theoretical concepts 
but they are experiences or facts of every day life and play an im- 
portant role in shaping and moulding the individual. Some of the con- 
cepts listed above are superfluous for our present discussion; some are 
relatively unimportant, and for some of them, other concepts may be 
substituted that are more adaptable to the scheme which will be set forth. 

The desires are the most suitable concepts on which to build. Desires 
are not abstractions, they are the result of intra-organic conditions plus a 
certain type of thinking. The exact nature of the organic conditions 


which arouse certain desires can be definitely traced; the origin of cer- 
tain of the other desires cannot at present be accounted for in a specific 
way. Dunlap 1 has employed the term appet to describe the something 
which in conjunction with anticipatory thinking constitutes a desire. 
Desires are actual events, processes or occurrences; they have an organic 
basis; they are wants. This notion of futurity seems to indicate that de- 
sires are always positive or that any anticipatory thinking is a desire. 
The notion of futurity alone does not constitute a desire nor is want a sat- 
isfactory criterion. One may think about future events in one of three 
ways; they may be desirable, undesirable or neutral. Whether an appet 
in conjunction with anticipatory thinking will be desirable, undesirable, 
or neutral will depend upon past experience, and the thinking which has 
preceded the arousal of the desire. 

The appet or organic condition for the desire to quench one's thirst 
is the dryness of the mucous membrane in the upper portion of the 
alimentary tract. The actual liquid desired for the satisfaction or relief 
of this organic condition will be determined by many other factors, 
including purpose and ideals. Under certain circumstances the desire, 
will be for water, even though the water may have a disagreeable flavor. 
The anticipatory thought of the particular water may be unpleasant, 
yet the desire prevails, since the organism rids itself of a more disagree- 
able or more unpleasant situation. Under other circumstances, the 
anticipatory thought may lead to a desire for alcohol; and under still 
other conditions, the desire may be for tomato or orange juice. The 
appet in these circumstances is fundamentally the same. The nature 
of the specific want or desire has been influenced by past experiences 
and anticipatory thinking. An individual with a strong prejudice 
against the consumption of intoxicating beverages may not have a desire 
for alcohol because of his ideals. If alcohol were prescribed as a stimu- 
lant for this same individual in order to overcome an organic difficulty, 
the desire for alcohol would arise. The original appet would be lacking, 
although another may be substituted. In spite of the fact that the 
essential characteristics of the original desire have been lost, purpose 
has been the deciding factor in action. Desires are without doubt 
purposive, but they are purposes of a definite sort. They are more than 
purposes, since they are influential in the determination of purposes 
which are not desires. How do the terms appet and desire compare 

1 The discussion of desires is based to a certain extent upon the chapter on Desires in 
the revised edition of Social Psychology by Knight Dunlap. 


with the terms drive, urge, instinct and innate tendency? The appet 
may be compared with the drive in that both are organic conditions or 
actions that furnish stimulation which sets the organism into action, 
although the term drive is used in a vague way to apply to a more gen- 
eral organic or psychological condition. In the conventional interpre- 
tation of drive it is the agent which activates the animal toward a specific 
goal, getting food, mating, and activity itself. The theorists have been 
little concerned with the mechanisms involved in the process, being con- 
tent with explaining drive, urge or tendency in terms of inherited or 
innate tendencies of reaction. The drive or urge is the force which 
impels an animal toward a particular goal, reward or incentive. Drive 
is somewhat similar to instinct, if the following definition is accepted 
for instinct. An instinct is an organized and relatively complex mode 
of response, characteristic of a given species, that has been phyloge- 
netically adapted to a specific type of environmental situation. In other 
words, an instinct is an innate, unlearned, response. The manifestation 
of an instinct does not require any learning, but may require maturation. 
The desire, on the contrary, is linked with and dependent upon learning. 
The only essential feature of the desire that depends upon inheritance 
is that the neural pathways be developed sufficiently to transmit pro- 
prioceptive afferent impulses which initiate anticipatory thinking. All 
primary reaction tendencies in man and animals have been called in- 
stincts. Avoidance has been called the fear instinct; association with 
other humans, the herd instinct; mating, the parental or amatory 
instinct; eating and procuring food, the food or self-preservative instinct; 
combing the hair, sex or self assertive instinct, and so on ad infinitum. 


Abnormalities of desire may be produced in numerous ways: 

(1) The actual appet underlying the desire may be affected, i.e., it 
may be too feeble or too intense. 

(2) The intensity of the appet may not correspond quantitatively to 
the satiation of the desire. 

(3) The appet may be normal but the anticipatory thinking or derived 
desires may be abnormal. 

(4) There may be some abnormality in the frequency of occurrence 
of the desire 

These underlying causes of an abnormality of desire cannot in most 
instances be attributed to only one of the specific factors listed above; 
more often the cause is the interrelation of the various factors mentioned. 


The organic basis for certain of the desires is fairly well established, 
the appets being identified with particular bodily tissues. For other 
desires, the basal tissue conditions can only be guessed. It is rather 
obvious then that our discussion of intensity or enfeeblement of appets 
is founded on insufficient data. The relation of the tissue condition to 
the desire itself is of the utmost importance, although the actual satis- 
faction of the desire as well as the method of satisfaction may exert a 
tremendous influence upon the appet. Desires may be either excessive 
or deficient. Some confusion exists in determining whether the desire is 
abnormal or whether the gratification of it is abnormal. Some indi- 
viduals may show an excessive gratification of a normal .desire; this ex- 
cessive gratification may lead to either an increase in desire or decrease 
in desire. Non-satisfaction of the desire may result in (a) the abolition 
or the reduction of the desire or (b) increasing the desire. 

Knowledge of how or when a desire is to be satisfied, if at all, will also 
affect the arousal of the desire. Fletcher, as reported by Masserman 
(474), showed that chimpanzees under the same degree of hunger 
motivation will work harder to obtain a large piece of food attached 
to a string than to obtain a small piece attached to the same string. 
The time between the appearance of the desire and its satisfaction will 
also be a potent factor in determining the subsequent characteristics 
of the desire. There is little uniformity of influence of these factors 
on the various desires. Expectation of food, water and rest within 
a specified time may effect these desires in entirely different ways. 
A desire for food may be enhanced or decreased by the knowledge that 
food will be served in a short time; it may be further complicated by 
knowledge that the food is bean soup or roast turkey. The knowl- 
edge that the food supply is exhausted and cannot be replenished 
may greatly increase the desire for food, and would also affect the 
desire for particular kinds of food. Lazarsfeld (475) in comparing the 
desires of children coming from an impoverished village in Austria with 
the desires of children coming from more favorable economic villages has 
shown that the total value of things desired at Christmas time was in a 
ratio two to three. The desire for preeminence, conformity, and the ama- 
tory desire are especially subject to foreknowledge and lack of it. The 
delay or non-satisfaction of a desire may result in organic changes so 
that the desire may be manifested in a totally different way or it may 
abolish the desire. In starvation, especially in the early stages, the desire 
for food increases; with further non-satisfaction the desire may be abated 
and finally disappear altogether. The excretory desires are subject to 


temporary modification and may even result in faulty habits of excre- 
tion through the delay in satisfying them. Activity and rest are subject 
to similar effects. Fat may result from failure to satisfy the desire for 
activity, which is an indirect modification of tissue, that inhibits the de- 
sire for activity. A more complex set of factors operate in determining the 
intensity of the preservation and abolition of the amatory desire, than any 
of the others. The variability of the strength of desires is partially due 
to the inclusion under the term strength of a number of different charac- 
teristics. These different characteristics may be (a) the intensity of the 
desire at any given moment, (b) the frequency of occurrence of the de- 
sire, (c) circumstances under which the desire is aroused. 

The intensity of a desire may actually be the intensity of the appet, 
but as has been pointed out earlier in the chapter, a proportional rela- 
tionship does not necessarily exist. Attention is the predominating fac- 
tor, since with dominance of attention there goes a dominance in per- 
ceptual patterns of objects and events which have a direct relation to the 
desired object. The frequency of the occurrence is often mistaken for 
intensity. If the desire for food having intensity A occurs ten times 
in one day, and occurs only four times at intensity A on another 
day, we are prone to say that the desires were stronger on the first day. 
Favorable or unfavorable circumstances existing at the time of the 
arousal of a desire may lead to the interpretation that the desire was 
stronger or weaker. A woman may be forbidden by her doctor to eat 
candy; under certain circumstances the desire is inhibited and under 
other circumstances it is satiated, although the intensity of the desire in 
both cases has been the same. 

How perversions of the desires arise is one of the problems in abnor- 
mal psychology. Before undertaking an explanation of the perversion, 
we have to clarify what is meant by perversion. We may speak of 
gluttons, drunkards, lazy people, etc.; what we are doing is merely de- 
scribing the ways in which people are satisfying their desires. These ac- 
tivities are not really perversions, except in so far as we may choose 
to classify them as such. In perversions, the desire is satisfied by some 
process or materials which are not satisfying to most people. There is 
no marked line of cleavage between a normal modification of a primary 
desire into a secondary desire or into a perversion. The man who 
plays golf is satisfying his desire for activity or preeminence; if he walks 
the floor all night he may be a manic; if he sits still all day he may be a 
catatonic; and if he walks the floor with the baby he is satisfying certain 
other desires. The perversions of the desires are practically determined 


in the same manner as other abnormalities; i.e., if the activities engaged 
in for their satisfaction are harmful to the individual or society, they 
are perverted. 

Perversions result from various causes. Failure of satisfaction of the 
desire in the normal way, over-indulgence of the desire, failure of ade- 
quate satisfaction of one desire and the resultant perversion of another, 
and learning under favorable circumstances are common causes of per- 
versions. The formation of normal secondary desires, which are bene- 
ficial and non-injurious, is through a learning process. Where new 
desires can be formed without the repression of other desires, there is a 
tendency to form them. The difference between a normal modification 
and a perversion is that the perversion interferes with adequate satis- 
faction of one of the primary desires or reduces the normal desire in 
strength or frequency, whereas a normal modification has no adverse 
effect on any of the primary desires or their satisfaction. Desires may 
be modified by the regressive spread of desire, from that which is thought 
of as a means to the primary end, and is therefore desired. A student, 
who plays football does not desire primarily to get tired, to get hurt, and 
to be humiliated in defeat. He may desire activity and since these 
other activities are means to an end, he desires these means. 

The desire to play football is not in all cases the primary desire; it is 
secondary, being the result of a spread from some more fundamental 
desire. It may be the desire of preeminence, the amatory desire, or even 
the alimentary desire if the student holds an athletic scholarship. The 
relation of the secondary desires to the primary desires cannot always be 
readily determined. 


The tissue structures underlying hunger and thirst normally give rise 
to the alimentary desires, although ideational factors or secondary 
desires operate in determining the way in which the desires are satisfied. 
The frequency and strength of the alimentary desires will depend par- 
tially upon the rate at which food and liquids are utilized in metabolic 
processes, although not entirely so. The desire for water or liquid is 
influenced by the rate of salivation, the rate of evaporation through the 
body pores and excretion through the kidneys. In general, the desire for 
liquids will arise before there is any serious depreciation of the liquid 
content of the body. Mayer-Gross and Walker (476) found that pref- 
erence for unknown liquids was partially determined by the blood sugar 
level. One hundred patients were tested for preference of solutions of 


saccharine, saline 5 per cent, sucrose 30 per cent, and water. Blood 
sugar levels were determined at the time of testing. When the blood 
sugar was below 50 mg. per cent, the 30 per cent sucrose solution was 
preferred, and when the blood sugar was greater than the above figure 
solution was rejected. The work of Cannon (477) and Carlson (478) 
indicated that hunger is definitely linked with stomach contractions. 
Doubt concerning the function of such contractions in arousing hunger 
has arisen since it has been shown that some individuals who have 
rhythmical contractions of the stomach do not have hunger and others 
who do have hunger do not have the rhythmical contractions. If 
emptiness of the stomach and contractions were the stimuli, then any 
solid material taken into the stomach should abolish hunger. This is 
true to a certain extent but ultimately hunger will occur unless material 
that can be assimilated is taken into the stomach. Davis (479) studied 
the selection of a variety of foods served simultaneously, by a group of 
thirteen infants that had just been weaned. The continuation of the 
study for a period of months indicated rather clearly that the children 
were capable of selecting a balanced diet and furthermore that the diet 
was regulated somewhat in accordance with changes in temperature and 
humidity. In a subsequent study by the same author (480) it was 
found that newly weaned children who had no experience with adult 
foods when allowed to select their own diets were able to maintain 
normal physical growth. The children selected 3600 meals at the rate 
of 4 per day. Examination showed that growth, red cell count and bone 
calcification were equal to accepted American standards. Rats on the 
other hand do not seem to be as successful, according to Scott, Smith 
and Verrtey (481). Twenty-one day old rats when offered a choice of 
diets containing casein, sucrose, hydrogenated vegetable oil and salts, 
did not select sufficient casein for normal growth and life maintenance. 
Twenty-two of 31 studied, died by the age of 58 days. Six to 12 month 
old rats fared better, since 60 per cent of these animals selected sufficient 
casein to maintain growth. Pregnant animals were found to increase 
their salt intake. Dill (482) found that food preferences of combat 
fliers were influenced by emotional tension. Aroma, flavor, and acquired 
preference played an important part in selection. In neurotic males, 
food aversions were more numerous than in normal males (Wallen, 483). 
Neurotics were inclined to have more unpleasant and disgusting associa- 
tions with disliked foods, and the author suggests that food aversions 
might be a useful indirect index of maladjustment. Work by Hausmann 
(484) shows that in the choice of sugar and saccharine (the former having 


food value and the latter not having any food value) rats seem to be 
able to select sugar since this supplied a tissue need. The desire for a 
particular kind of food is controlled by quite a different mechanism 
from that of stomach contractions and it is highly probable that hunger 
is also controlled in a similar manner. 

The excesses and deficiencies of the alimentary desire are clearly recog- 
nized; perversions are not as readily distinguishable since the perversion 
of one desire may depend to a considerable extent upon the interaction 
of the other desires. Deficiency in the alimentary desire ranges from 
weak appetites to total abstinence from food or liquid. This lack of the 
desire for food and liquid is technically designated as anorexia and adip- 
sia respectively. 

People who eat relatively little food or drink small quantities of liquid 
usually pass unnoticed unless some other abnormal condition develops 
as a result of these deficiencies. If the individual refuses to eat any food 
or drink any liquid, we may be dealing with either a psychopathic case 
or an organic disturbance unaccompanied by a mental aberration. 

Excessive food desire is popularly called gluttony and is technically 
bulimia; excessive thirst is termed polydipsia. If the alimentary desire is 
directed toward a specific food or liquid, a technical name is applied to 
that condition; for example dipsomania is the uncontrollable desire for 
intoxicating beverages. 

The physiological conditions underlying the appet have already been 
mentioned in a general way. Some derangement of the metabolic proc- 
esses would be reflected in the lack of desire for food; stasis (popularly 
referred to as auto-intoxication) of the stomach or intestines may poison 
the end organs located in these regions so that no afferent impulses are 
set up; flatulence from poor digestion may lead to fatigue of the end 
organs or their terminals in the brain because of continual incoming stim- 
ulation or because the air chambers created may prevent the chemical 
stimulation derived from the food from affecting the end organs; tumors, 
and many other factors may account for the lack of the appet. Keys 
(485) work on human starvation points out clearly the psychological and 
physiological effects produced. In his experiment 32 males between the 
ages of 20 and 33 were kept on a 3150 caloric diet per day. This was 
continued for a 3 month period during which the subjects were tested. 
They were then placed on 1760 calories per day with 49 grams of protein 
added for 6 months. They were again tested. There was evidence of 
severe weakness, depression, fatigue, anemia, brachycardia, edema, 24 
per cent loss in weight and a small loss of plasma protein. There were 


no adverse effects upon vision, hearing, and general intelligence, although 
initiative was impaired and small adverse effects were detected in 
coordination and speed. Full recovery from the adverse effects occurred 
in from 8 to 12 months when the subjects were returned to an adequate 

Physiological factors for explaining an increase in the intensity of the 
appet are more difficult to localize. The vast amount of experimental 
work on this topic is gradually yielding a better understanding of the 
whole problem. Not only is information being obtained about the 
appet for a specific food or chemical but also concerning the general 
hunger appet. Young (486) and Richter (487) have carried out a 
variety of experimental investigations and have collected much of the 
experimental literature on this topic. Operative procedures which alter 
the basic needs of rats show that adrenalectomy results in the consump- 
tion of large amounts of sodium ; parathyroidectomy increases the intake 
of calcium; pancreatectomized rats ingest large amounts of fats and 
casein and but little sucrose; however, rachitic rats do not choose an 
optimal diet for overcoming the condition. Clark and Clausen (488) 
support the notion that adrenalectomy results in increased salt intake 
and found further that injections of adrenal cortical hormones tended 
to return the salt intake to a normal level. Warkentin et al. (489) have 
demonstrated the influence of metabolic rate on total food intake in 
rats. Thyroidectomized rats showed a marked decrease in intake, and 
hyperthyroid rats ate much more foood than normal animals. In their 
selection of specific foods it appears that the choices are altered so that 
they obtain a high caloric intake. Donhoffer and Vonotsky (490) in- 
jected .02 to .04 mgms. of thyroxine daily into white mice, which pro- 
duced within 3 to 6 days a rise in oxygen consumption and food intake. 
The additional food intake was largely carbohydrates. Brooks, Lock- 
wood and Wiggins (491) found that hypothalamic lesions in rats increased 
the amount of food eaten at a meal. 

Growth in fatty and muscular tissue may explain an increase in appet 
if the theory is accepted that there is an underlying tissue need re- 
sponsible. This theory receives additional support from the observa- 
tions on patients with diabetes mellitus. Untreated cases show 
voracious appetites and intense thirst; since these patients void large 
quantities of urine containing sugar, it might be inferred that the 
polydipsia is a result of high blood sugar concentrations and withdrawal 
of fluid from the intestines, hence the appet for water. Partial con- 
traction of the muscles of the stomach and intestines may set up 


continual afferent impulses which are not strong enough to fatigue the 
central or peripheral neural tissue and so cause an increase in intensity 
due to greater frequency of stimulation. 

If the theory that contractions of the stomach are essential for the 
arousal of the appetite is true, then it must be assumed that the hunger 
contractions are abnormally strong or that the nerve endings are hyper- 
excitable. Some idiots and insane people show bulimia but the informa- 
tion which is available is too scanty to be of much use in determining 
the actual mechanisms involved. It is probable that a lesion or defect 
is present in the higher regions of the brain and endocrine system since 
accidental lesions will in some instances produce an analogous condition. 

Reiss (492) in a careful study of a case of anorexia nervosa set forth 
the difficulties of distinguishing between the organic and the ideational 
bases of the disorder. The photographs in plate III show very clearly 
the changes manifested. The patient was disappointed in a love affair 
and subsequently lost the desire for food. With the introduction of 
rationing she excused herself from eating thereby leaving more for other 
people. There was no evidence of a major psychosis. During a twelve- 
months period in which diet changes and psychotherapy were instituted, 
the changes shown in the top and bottom photographs occurred. It 
might be concluded that the causal factors were entirely psychological. 
However, it has been found that other cases do not respond unless 
adjunct therapy with hormones, particularly those of the pituitary 
gland, is instituted. 

The ideational element connected with the alimentary desire is es- 
pecially important. In spite of the fact that the physiological and neuro- 
logical factors underlying the appet are normal, anorexia and bulimia 
occur in some cases. A case of anorexia from Hollingworth was cited in 
a previous chapter. The ideational elements in the situations were alone 
responsible for the lack of the desire for food. The normal individual 
who sees dirt in food or a fly in the jam may lose the desire for that kind 
of food in the future. Many disturbances of the desire for specific kinds 
of food in "so-called" normal people can be definitely traced to anticipa- 
tory thinking colored by previous experience or by hearing the expe- 
riences of others. The notion that various food combinations cannot be 
eaten at the same meal, or that particular foods cannot be eaten with 
impunity occurs because of a lack of knowledge of physiology. The 
bugaboo of sea food and ice cream, certain kinds of fruit and milk prod- 
ucts, acidosis and other common gastric ailments need not give the 
average person any difficulty provided they reorganize their ideas con- 
cerning the harmfulness of these foods. 



Reproduced by permission from J. Mental Science, 1943 


The abnormal individual under appropriate ideational conditions 
would probably lose the desire for all kinds of food. This seems to be 
true in many cases of hysteria and depressive states in which phobias 
play a dominant role. 

Fenichel (493) of the psychoanalytical school contends that if oral 
impulses are subjected to repression, inhibition of food intake, uncon- 
sciously reminiscent of the objects desired by the repressed oral-erotic 
strivings, occurs. These oral inhibitions may be displaced onto other 
activities with a hidden oral meaning, such as drinking, smoking, social 
activities or reading. His position is made clear in the following 
quotation: 2 

"Orality, as the oldest field of instinctual conflicts, can be used later on to express any 
other instinctual conflicts, especially if experiences in infancy have left an oral fixation 
that facilitates a displacement from subsequent frustrations (primal scenes, birth of 
siblings) to oral conflicts. Any conflict between activity and receptivity may result in 
eating disturbances. Since parents who have had difficulties in helping their children to 
make an adequate adjustment on an oral level usually have difficulties again in training 
their children for cleanliness, and since, among the anal frustrations, the prohibition of 
taking feces into the mouth is especially stressed, it is understandable that anal conflicts, 
too, may be expressed by children through oral inhibitions, through inhibitions in eating, 
as well as through inhibitions in speech. If a refusal to eat has an especially stubborn 
character, expressing primarily the attitude 'I will not let myself be controlled; I eat when 
and what I like', then anal components are mainly involved. 

In the genital sphere, eating usually has the unconscious significance of 'becoming 
pregnant/ and this equation, too, may cause various inhibitions in eating. Since a high 
percentage of all oral pregnancy theories are based on the belief that the woman eats the 
man's penis, revenge types of feminine castration complexes, if inhibited may also result 
in eating inhibitions. 

Specifically disliked kinds of food unconsciously symbolize milk, breast, penis, or feces. 
However, a refusal of food does not necessarily represent a repression of eating cravings. 
A specific food may be rejected obstinately because it is not the desired one: 'I do not want 
this food but that'; or 'I do not want food but love (or penis, or a child).' In this in- 
stance, it is not a drive that is refused but the acceptance of a substitute. 

Specific eating taboos may secondarily become rationalized or idealized. It is cruel to 
eat animals, or dirty or unhygienic to eat this or that. Rationalizations of this kind are 
often suggested by modern food theories which tend to prohibit naive sexual pleasure in 
food and to connect eating with the superego sphere. You are not supposed to eat what 
is good but rather 'what is good for you.' 

If an eating taboo in later life is neither rationalized nor fixated in ego-dystonic con- 
versions like vomiting or spasms of the jaws but becomes the core of a more or less ego- 
syntonic pathological behavior, this is called anorexia nervosa. Anorexia regularly can be 
traced back to eating disturbances in childhood which under certain libido-economic 

2 Fenichel, O. Reprinted by permission from The Psychoanalytic Theory of Neurosis. 
W. W. Norton Co., 1945. 


circumstances are subsequently taken up again. Like the disturbances in childhood, 
later anorexias, too, may have a very different dynamic significance. It may be a simple 
hysterical symptom expressing the fear of an orally perceived pregnancy or of unconscious 
sadistic wishes. It may be a part of an ascetic reaction formation in a compulsion neurosis. 
It may be an affect equivalent in a depression, in which the symptom of refusal of food 
makes its appearance before other signs of the depression are developed. It may be a 
sign of the refusal of any contact with the objective world in an incipient schizophrenia." 

The varieties of ideation that affect the desire for food adversely are 
too numerous to treat further. These forms of lack of desire for food 
may be overcome by a systematization of the ideational processes and 
by substitution of the secondary desires to strengthen the food purposes. 

The ideational factors which operate in building up excesses in the 
desire for food are really factors which influence predominantly the way 
in which normal desires are satisfied. 

Habits are influential in determining modes of satisfaction. We eat 
many times when we are not hungry, the purpose being reenforced by 
such desires as conformity, activity and the amatory desire. Habits 
once established through any one of the secondary desires may arouse 
indirectly the primary desire of food. Katz (494) has shown that envi- 
ronmental influences are very potent in the satiation of a desire for food. 
A hen under the same condition of hunger will eat less from a large pile 
of food than from a small pile and after apparent satisfaction of hunger 
will eat again if other hens begin eating. Likewise if offered another 
kind of food the hen will begin eating again and may repeat the process 
for as many as five or six varieties. She will also eat more of mixed than 
unmixed food. These facts are in agreement with those observed in 
humans. Morse and Chittenden (495) have found that children eat 
more efficiently when served a medium helping rather than a small 
or large helping. It is obvious then that the alimentary desire can be 
partially regulated through habits established and through the control 
of the secondary desires. The perversions of the alimentary desires 
are not numerous although the desire for a specific kind of food or liquid 
varies widely for different individuals. Parorexia is the most usual 
perversion of the desire for food. This is usually ascribed to the idea- 
tional factors accompanying the hunger appet, although the condition 
may be referred to the actual tissue needs. Rats' tendency to eat 
lead under certain conditions, the eating of bones by cattle whose diet 
is poor in phosphorous and eating of wool by sheep indicate that these 
perversions are due to chemical needs. The consumption of clay, 
glass, stones and other non-nutritious materials in time of famine by 


humans can be attributed to the thwarting of the normal desire for 
food. Perversion arises in some humans in spite of the fact that all 
chemical needs of the organism are available. These perversions can 
be explained only by ideational factors. It is possible that the collecting 
mania with greed and avarice are perversions of the alimentary desires,. 
The lack of satisfaction of the alimentary desires among misers is well 

Psychoanalysts hold that greed of any kind is directly traceable to 
oral eroticism. Oral eroticism is first concerned with the pleasurable 
feelings engendered by autoerotic stimulation of the lips, tongue, etc. 
This is shifted later to the incorporation of objects into the body. By 
incorporation into the body, union of the objects takes place, or the 
individuals obtain primary identification with the object. Thus, with 
individuals fixated at the oral level, many kinds of collecting activities 
are ascribed to this principle. There are cases in which the individuals 
pursue similar behavior, although the behavior itself is now dependent 
upon anal factors. These anal characteristics grow out of conflict over 
cleanliness and such matters as toilet training. The child possesses the 
power to postpone or gains mastery over both his instinctual drives 
(anal gratification) or the omnipotent adult (environment). Frugality 
is a continuation of anal habit of retention. Obstinacy is a striving for 
a feeling of mastery over environment and restriction of self esteem, and 
may be centered in the habit of fecal retention. Money like feces rep- 
resents mastery over environment in that the individual can retain both 
money and feces until disposed to get rid of them. Money then be- 
comes an object of pleasure. 

Animals tend to hoard food under appropriate internal stress and 
environmental conditions. Hunt (496) separated litter mate rats 
about four weeks old into two groups. One group was allowed un- 
limited food, and the food of the other group was restricted. After 
about five months of unlimited food for both groups, it was found that 
the group in which food was restricted in early life hoarded about two 
and one half times as many food pellets as the unrestricted group. 
Stellar (497) has carried this form of investigation into the physiological 
factors that may be in operation. Since the amount of hoarding was 
related to food deprivation, he assumed that the activity may be related 
to tissue concentration of carbohydrates. He therefore argued that 
glucose and epinephrine may decrease hoarding by raising the carbo- 
hydrate concentration in the blood, muscles, and liver; that insulin, 
which has an opposite effect, may increase hoarding. Groups of rats 


injected with these drugs partially substantiated his hypothesis. Epi- 
nephrine increased hoarding, but insulin and glucose had little effect. 

Hunt, Schlosberg, Solomon and Stellar (498) in extending earlier ex- 
perimentation demonstrated that satiated adult animals showed little 
hoarding even though they experienced frustration; they did, however, 
eat more during the adult feeding frustration trials. This suggested to 
the authors that eating and hoarding could be regarded as alternate 
expressions of infantile feeding frustrations. Bindra (499) also con- 
cluded that hoarding of preferred foods is more prevalent. This par- 
tially substantiates the previous workers' conclusion that hoarding and 
appetite are alternate forms of behavior, but he concluded that a physio- 
logical basis was not necessary for hoarding behavior. 

The role played by the alimentary desires in feelings of various kinds 
vill be considered later in this chapter. 


The excretory activities are not restricted to a single process of the 
bladder and rectum. The arousal of these activities are dependent upon 
a complex of activities associated with pressure upon the nerve endings 
in these organs. Normally, defecation and urination occur upon stimu- 
lation. Many physiological factors control the rate of excretion of 
urine which in turn influences the pressure resulting in the bladder. 
The size of the bladder and the strength of the muscles of the bladder 
walls and of the sphincter will also partially determine the frequency. 
Although the urinary and defecatory functions may proceed under 
physiological stimulation alone, if the ideational factors are allowed to 
disintegrate, these functions tend to become disordered. The impor- 
tance of the ideational element is demonstrated clearly by the inability to 
urinate under unusual circumstances. The use of running water by 
physicians when collecting specimens is nothing more than the reestab- 
lishing of the ideational or associated factors with the physiological 
process. The most frequent disorders of the urinary functions are 
retention of urine (anuresis) and the incontinence of urine (enuresis). 
Retention of urine occurs with many febrile diseases. Ideational factors 
will not ordinarily cause retention for long periods of time since the dis- 
comfort occasioned by bladder distention becomes very acute. 

Some principles of a similar nature to those mentioned in connection 
with the retention of feces could be applied to the retention of urine. 
These will not be elaborated further. 

Enuresis, on the contrary, seems to be decidedly influenced by idea- 


tional factors. The involuntary voiding of urine may occur at any time 
during the day or night, and the methods of dealing with these two 
varieties of enuresis must be appropriately met. Enuresis is always 
encountered in infants. With proper training both the nocturnal and 
diurnal types are usually overcome before the end of the third year; in 
some cases the diurnal enuresis may be voluntarily controlled as early 
as the tenth month. Maturation of the higher centers of the brain is 
required before the reflex action of the bladder is brought under control. 
Lack of maturation or development which is found in idiots and imbeciles 
prevents these individuals from ever gaining voluntary control of the 
functions. The instability and the inhibition of the higher centers is 
related to the lumbar centers in such a way that any imbalance between 
them may result in incontinence. Hyper-acidity of the urine combined 
with weak cerebral inhibition may readily result in enuresis. In the 
majority of cases of enuresis, the underlying physiological cause cannot 
be determined. Stuttering enuresis belongs to this category; it is so 
named since it compares with the act of stuttering and many other tics. 
There is incoordination of neural innervation of the sphincter muscles 
and the muscles of the bladder. 

Thorne (500) studied the incidence of nocturnal enuresis after age 5 in 
1000 consecutive army selectees and found that 16 per cent reported the 
condition after this age. Two and five tenths per cent did not gain 
bladder control until after 18 years. There was evidence of associated 
neurosis or mental disturbance in 63 per cent of these cases. Among 
inmates of a school for mental defectives 83.8 per cent of idiots were 
troubled with nocturnal enuresis. 

Mowrer and Mowrer (501) and Smith (502) have summarized the 
theories of and treatment for enuresis. 

The general theories are as follows : 

i. Enuresis is a neurotic symptom whereby the child gains sexual satisfaction, 
a. Enuresis is a form of conversion hysteria in which deep-seated anxiety is con- 
verted into a physical dysfunction. 

3. Enuresis is a habit engaged in whereby the child gains the right of self-assertion 

or retaliation; i.e. it is a form of compensation. 

4. Enuresis is due to inadequate training. 

The first of these theories assumes that urination is a pleasurable 
biological function. Observations that a full bladder may produce an 
erection during sleep and that male infants have tumescence even during 
the waking hours when urination takes place have been used in the 
arguments that urination is definitely symptomatic of or a substitute 


for sexual expression. Another symptom used as evidence in connection 
with the theory is the convenience dream. A quotation from Mowrer 
and Mowrer will make this point clear: "enuretic children very often 
have the most vivid 'dreams of convenience' just before or during the 
act of urinating in bed. Under these circumstances, the sleeping child, 
instead of awakening to the stimulation produced by a distended 
bladder, fancies himself in a toilet, swimming in a pool, at the beach, 
alone in the forest or in some other secluded place where urination, 
which he now indulges in, would be allowable; in this way the child 
dismisses the otherwise disturbing fact that he is in bed and avoids the 
discomfort of awakening and really going to the toilet." 

That there is anything sexual in these dreams is improbable. The 
dreams can be explained on a basis of nervous excitation originating in 
the bladder which arouses ideational processes in the cerebral hemispheres, 
but which is not of sufficient intensity to set off the urinary reflex. 

The essential points of the second, third, and fourth theories are 
embodied in the subsequent quotations from the source previously given. 
In regard to the second theory they state: "Fearfulness has often been 
assumed to be a primary cause of enuresis, and it may indeed be in some 
cases; but what would seem to be more frequently true is that the 
enuresis is the primary condition and fearfulness a consequence, arising 
from the threats and punishments which are often resorted to by adults 
in attempting to eliminate this condition. Many children have been so 
harshly dealt with in connection with toilet training that they live in 
real terror of nocturnal lapses; and once the disgracefulness of bed- 
wetting, as reflected by the attitudes of adults, is accepted by the child 
and "internalized," a kind of vicious circle is often set up, the enuresis 
creating greater shame and apprehensiveness, which in turn may further 
aggravate the enuresis. In such cases it seems reasonable to infer that 
the enuresis can be eliminated or at least materially helped by relieving 
the child of his old anxieties; but this is usually a long tedious process." 

The third theory, similar to the first and second, is formed on the 
fact that enuresis is a symptom of some personality disorder. This 
theory has been summarized by Mowrer and Mowrer in the following 
manner: "Slowness in the acquisition of socially approved habits of 
elimination and periodic lapses in the exercise of these habits seem to 
be a form of self-assertion and retaliation by the infantile personality. 
The child who has discovered how effectively he can outrage the sur- 
rogates of the culture who are assigned to him in the form of his father 
and mother by the act of nocturnal enuresis, an act which is committed 


while he is asleep and therefore one for which he is usually not held 
fully accountable, has at his disposal a peculiarly effective outlet for 
his resentments: in this act he achieves real retaliation and at the same 
time tends to avoid the consequences which would follow if he committed 
an equally annoying act during his waking hours." 

The fourth theory seems the most plausible. The child who has not 
learned bladder control has as yet not been able to respond selectively 
to the impulses set up by a relatively slightly distended bladder and 
the numerous other proprioceptive and exteroceptive stimuli that occur 
during sleep. This same situation may hold true for diurnal enuresis. 
If enuresis is to be overcome, some special training or some cues must 
be given that will enable the child to learn to respond selectively to the 
bladder clues. 

A wide variety of curative measures have been attempted. The 
measures include drugs, hormones, diets, operations, irrigations, sug- 
gestion, analysis and habit training. Kugelmass' experiment (503) on 
the use of androgen therapy is typical of these studies. Seventy-five 
cases with or without emotional difficulty which failed to respond to 
other forms of therapy were administered either methyl testosterone or 
testosterone proprionate. Fifty-nine were cured; 10 were improved; 
and 6 failed to benefit. If these results can be duplicated, this approach 
seems to be the best form of therapy available and casts doubt upon 
much of the psychoanalytical and psychological theorizing. All of the 
methods have been attended by some success according to their pro- 
ponents. Which method of treatment should be used will depend 
somewhat upon the theory that one is defending. 

For diurnal enuresis, Hermann (504) recommends that the individual 
practice urinating a small quantity, stopping at this point and repeating 
the process. In this way the patient trains himself in the voluntary 
execution of the act. Dunlap (505) has amplified this theory placing 
emphasis on the ideational processes in conjunction with the practice. 
Since emotion such as fear seems to be the cause in some cases, it is 
desirable to approach the problem from the point of view of kindly 
cooperation, rather than by prohibition and punishment. 

Recently, the use of mechanical devices to indicate the moment when 
nocturnal urination commences have been introduced. These devices 
employ pads that will convey current when wet but will serve as non- 
conductors when dry. When the circuit is closed through moisture, a 
bell rings or a light flashes. The theory and practical application of 
these instruments in cases of enuresis is given in the Mowrer survey. 


In general practice, in attempting to train bladder control, the child 
is awakened just before it would normally have to evacuate the bladder. 
In time, this awakening is associated with a particular bladder tension. 
With the new mechanical device, the maximal tension of the bladder 
rather than a somewhat lesser tension becomes associated with awaken- 
ing and enuresis is overcome. 

Restriction or limitation of liquids before bedtime may also be of 
practical advantage in nocturnal urination, as reported by Beyme (506). 

Increased frequency of urination is found in old age; with prostate 
disease; with cystitis; and in nervous disorders. The quantity of urine 
voided may be small but due to increased irritability of the nervous sys- 
tem, the desire to urinate occurs more frequently. 


The sex desire may be broken up into two more fundamental desires; 
namely, the desire for reproduction and the amorous desire. 

The amatory desire is the desire for stimulation by a person of the op- 
posite sex. This stimulation may involve any one of the special senses 
and does not necessarily give rise to a specific desire of coitus or even a 
general desire of coitus. The reproductive desire should be applied to 
sexual union for the specific purposes of procreation. The manner in 
which the amorous and reproductive desires are interwoven is determined 
to a certain extent by the processes that are common to both. There are 
at least three kinds of processes related to the arousal of these desires: 
(a) reproductive processes, (b) the genital processes and (c ) amatory proc- 
esses. These processes correspond closely to physiological conditions 
of the organism and the appet for the arousal of the desire may be 
localized in some aspect of one of the processes. 

The reproductive processes include the implantation of the spermato- 
zoa, fertilization, gestation and parturition. Although the amatory proc- 
esses may share a part in the reproduction process, they are not strictly 
amatory if engaged in for the purpose of reproduction. In fact, the 
amatory processes cannot be identified in most cases as reproductive 
since coitus in general does not take place for the specific purpose of re- 
production. No physiological processes occur in the implantation of the 
spermatozoa for fertilization beyond those that occur in the normal grat- 
ification of the amatory desire. This is probably true for both sexes since 
it is extremely doubtful whether ideational factors in any way influence 
the probability of fertilization unless coitus is voluntarily terminated by 
the male or unless contraceptive measures are undertaken. Some people 


may argue that the reproductive desire would not arise without the in- 
clusion of the amatory processes. This is, of course, a fallacious notion. 
Some humans with strong religious convictions indulge in coitus only 
for the specific purpose of reproduction. Stone (507) has demonstrated 
the initial copulatory response in rats even after the afferent impulses 
have been cut off from the skin of the anterior belly wall, the inguinal 
region, the ventral and lateral portions of the scrotum, the vibrissae, 
the visual, olfactory, and gustatory receptors. The destruction of the 
olfactory bulbs, the cortex of the frontal, parietal, and occipital regions 
of the cerebrum in rabbits does not inhibit the reproductive response. 
Beach (508) has found similar results with rats, although he believes 
that the cortex is essential in the female's tendency to solicit sexual 
attentions of the male. He states, in addition, that the neopallium is 
responsible for active exploration and pursuit of the sexual object by the 
animal playing the male role. These examples show the possibility 
of the activity of the reproductive processes even in the absence of 
what may be termed the amatory processes in animals. 

The genital processes are those directly related to the genitalia. The 
stimulation and response of these organs are necessarily involved in 
reproduction and in some cases in the amorous processes. The amorous 
processes may be aroused in some instances without the genital processes. 
Normal genital stimulation is contact, pressure, friction, and possibly 
warmth. The response of the genitalia to stimulation is of a specific na- 
ture and differs qualitatively from the sensation derived from contact 
and pressure with other parts of the body. The receptors of the genitals 
produce sensations of an exciting nature, which differ in this respect from 
the sensations derived from the ordinary receptors for pressure and touch. 
The increase in or lack of sensitivity of the genitalia is highly important 
in explaining many anomalies of sex behavior. The actual sensitivity of 
the sex organs seems to be modified by the absence or presence of the 
amatory processes. 

The effects of genital stimulation may be both local and general. The 
immediate local effects are those produced on the sex organs; the general 
effects are much more far reaching. It is possible that the general effects 
may be produced without the local effects and vice versa. The genital 
responses both localized and general include activities of all varieties 
of effectors, glandular, vascular, and muscular. Changes in respiration, 
the heart rate, secretion of the sweat glands and various glands of 
internal type, changes in circulation, and rhythmical muscular contrac- 
tions are to be classed among the general effects. The more localized 


effects are to be found in the sex organs and their accessory mecha- 
nisms. Many of these responses can be observed when the organism is 
stimulated through other sensory channels; hence it is obvious that all 
disorders arising in these response mechanisms cannot be attributed to 
the "sex" as the Freudians maintain. 

The amatory processes are not as uniform in pattern as those of the 
reproductive and genital processes. The behavior characteristic of the 
amatory process is varied; it may or may not have as one of its chief 
components sex union. Certainly much of our amatory behavior is not 
directed toward this goal. Amatory behavior includes a rather complex 
group of social activities, such as dancing, going to the theatre, playing 
games, and conversation. One might list also more direct amatory be- 
havior, such as kissing, fondling, caressing, primping and coquetting. 
Any activity of a heterosexual nature may be a part of the process. 
The variability of the process prevents further description and will be 
elaborated upon in discussing the amatory desire. 

The physiological processes underlying these fundamental desires are 
difficult to analyze. Various physiological conditions have been held 
responsible, among which may be listed in the male, turgescence of the 
glans penis, general circulatory changes, secretions of the testes, pos- 
sibly the secretion of the prostate and the fullness of the vas deferens. 
In the female, functions similar to those in the male may apply. The 
cyclic variation of the female, and the correponding waxing and waning 
of the amorous desire have been observed from historical times. The 
physiological factors which produce menstruation have been carefully 
worked out and have been suggested as possible causes. One point, 
however, is still obscure. We cannot say with certainty whether the 
rise and fall of the amorous desire is due entirely to the physiological 
factors or whether it is due partially to anticipatory thinking in con- 
nection with moral precepts of uncleanliness during the menstrual flow. 
The result is due in all probability to both factors. Eagleson (509) and 
Johnson (510) have demonstrated that there is a general lowering of 
efficiency both physiologically and psychologically shortly preceding and 
during the menstrual discharge and a marked increase immediately 
following which would probably influence both the amatory and repro- 
ductive desires. 

The reproductive and amatory desires are so closely allied that any 
abnormality of the amatory desire may affect the reproductive desire 
and vice versa. Of course, the relation of the strength of the desire to 
the method of satisfaction does not necessarily develop with correspond- 


ing steps. The ideational factors are of too great moment. If we as- 
sume that the amatory desire is normal and that the physiological and 
anatomical mechanisms are normal, unusual manifestations of the repro- 
ductive desire will be found. In a primitive system of civilization and 
among animals, the normal reproductive desire leads to as many off- 
spring as possible. Since we are not living under such a system another 
criterion of normality of the reproductive desire must be employed. 
The average number of children of the American family is about 3.8. 
It is not fair to assume, however, that in families smaller or larger in size, 
the reproductive desire is weaker or stronger. What is probably the 
case is that the other desires are more or less gratified or are less intense 
or more intense. 

The possibility of gratification of the desires for rest, activity and 
preeminence, will certainly modify the attitude toward reproduction. 
The poorer classes of our population have large families partially as a 
result of the lack of satisfaction of their other desires. Since reproduc- 
tion occurs in many cases because of the intensity of the amatory desire 
even with a strong aversion toward reproduction, knowledge of contra- 
ception is probably even more important. 

Deficiencies of the amatory desire may occur in both sexes although 
the female is more subject than the male. The deficiency is usually 
restricted to some particular pattern of the process or behavior. The 
term impotence is usually applied to male hyposexuality, while frigidity 
is applied to female deficiency. Frigidity sometimes referred to as 
anesthesia sexualis may be total or partial, congenital or acquired. The 
physiological development of the sexual organs and the muscle reflexes 
are essential for the development of the amorous desire and in spite of a 
normal development of these, there are cases of failure of the amatory 
desire. Frigidity may be expected in some cases of old age, before 
puberty and even for a period in some girls after marriage. Its dis- 
appearance in these latter cases may be expected with adequate develop- 
ment of the sex relations. Various factors may operate in causing 
acquired frigidity. Improper stimulation of the female genitalia, dys- 
pareunia, painful stimulation due to laceration, and incomplete satis- 
faction due to withdrawal of the male sex organ may all produce frigidity. 
Fear of venereal disease, fear of pregnancy, and masturbation may be 
powerful factors in the development of the condition. 

The Freudian school of analysts explains frigidity on one of several 
postulates: Anxiety about danger which is unconsciously associated with 
the sexual aim gives rise to the failure to achieve interest in general 


sexual affairs or in experiencing the orgasm. One of the unconscious 
aims involves the Oe'dipus complex. The sexual partner may be com- 
pared with the father. Another fear is loss of control at time of climax, 
which may be unconsciously thought of as loss of control of the sphincters 
of the bladder and anus. A third area of difficulty stems out of the 
arrested development of the erogenous zones at the level of the clitoris, 
whereas development should normally proceed to the vagina. Since 
the former may be associated with practices of masturbation, guilt 
associated with these practices may inhibit sexual satisfaction. 

Impotence, according to the Freudian analysts, is due to a physical 
condition arising from dangers to the ego. The ego derives sexual 
pleasure if such pleasure is not connected with danger. In the child, un- 
controlled sexual aims are always subjected to threat from the environ- 
ment, therefore sexual expression must be curtailed in many ways. The 
Oedipus complex again intrudes into the picture. The male becomes 
impotent because of a sensual attachment for the mother and prohibi- 
tion of sensual interest in the mother is very intense. Feminine partners 
may not arouse interest either because they are inferior to the mother 
or because they represent the mother. Males with passive homosexual 
trends cannot achieve heterosexual relations because of the identifica- 
tion of themselves with women. Other analysts hold that impotence is 
engendered by organic deficiency which gives rise to a feeling of in- 
feriority. Crider (511) claims that impotence is somewhat of a con- 
ditioned reaction in which the male has some anxiety about his sexual 
powers. In order to prove his virility he attempts intercourse with 
great apprehension, 'which tends to produce failure. The failure en- 
hances the anxiety which simply increases the inability. 

Wolbarst (512) in studying male potency felt that impotence in the 
husband was often influenced by the change in the physical appearance 
of the wife with age. If one accepts the Freudian viewpoint of mother 
identification, his contentions might have some import, since the wife 
may tend to become more similar to the mother as she grows older. 

The strength of the amatory desire cannot be rated on any known 
scale. Davis (513), Huhner (514), and Terman (515) have attempted 
to determine norms for one aspect of the amatory desire. The measure 
which they have used is the number of times coitus is indulged in per 
week or month. Terman compared frequency of coitus and desired fre- 
quency of coitus for a "passionate" group of wives with a "non-pas- 
sionate" group of wives. The frequency of coitus of the former group 
averaged 12.6 per month while the latter group averaged 3.6 per month. 


The desire in the former group averaged 14.2 times per month and in 
the latter group 1.8 times per month. The data are unsatisfactory 
since most people reporting were those who had only one mate. It is 
almost certain that different stimulation may have resulted in quite a 
different quantitative expression of the amatory desire. Huhner, ad- 
mitting that his data are open to criticism, finds that the sexual passion 
of sterile women is reduced in 40 per cent of the cases. Kinsey, 
Pomeroy, and Martin (516) give comparable data on the frequency of 
sexual outlets among males. They find the range from o per week to 29 
per week, the mean 3.27 for males under 30 and the mean 2.34 for the 
total population of males. Some types of frigidity due to physiological 
or psychological causes can be corrected. Anesthesia sexualis due to 
excessive modesty may be alleviated to a certain extent by drugs which 
act on the higher neural centers or by erotic associations. The other 
extreme of the amatory desire is called satyriasis in the male and nympho- 
mania in the female. These terms, however, imply pathological condi- 
tions and hence should not apply to those cases in which the amatory 
desire is very strong. In satyriasis and nymphomania the amatory 
desire is so powerful that it dominates the entire activity of the indi- 
viduals. The actual causes may be local, cerebral, or psychological. 
Irritation of the sex organs may be the basic factor, or a lesion of the 
brain may set up reflex activity. On the other hand, constant reading 
of salacious literature or erotic day dreaming may be sufficient causes 
to bring it about. 

The Freudians hold that hypersexuality is brought about by the lack 
of real satisfaction of the sex impulses. Deprived of real satisfaction 
the individual attempts again and again to obtain satisfaction but never 
succeeds in obtaining relaxation and relief of tensions. These indi- 
viduals' sexual activities are primarily designed to overcome inner feel- 
ings of inferiority by proof of erotic success. Kinsey et al (517) call 
attention to mistaken notions of frequency of both hypo- and hyper- 
sexual outlets and stress, on the physiological side, such factors as age, 
metabolic level, nutrition, vitamins, and endocrine levels. Psycho- 
logically they-stress the fact that frequency is controlled by conditioning 
through early experience, the nature of outlets, mores, occupation, edu- 
cation, and many other factors. In general, the picture is very compli- 
cated and the simple "analytic" explanations seem farfetched. 

The other perversions of the amatory desire which will be discussed 
are (a) auto-erotism, () homosexuality, (c) fetichism, (d) sadism, (i) mas- 
ochism, (/) zooerasty, (g) pedophilia erotica, and (h) inspectionism. 


Auto-erotism is self-stimulation of the sex processes. Although there 
are several forms of this behavior, our discussion will be confined to 
masturbation. The analysts have looked upon this practice as one 
stage of normal sexual development, and this assumption can be par- 
tially justified in view of the large number of both boys and girls who 
engage in the practice sporadically at some period in their lives. (Esti- 
mates range from 85 per cent to 96 per cent in males). Masturbation 
usually results from the deprivation of other outlets of the amatory 
desire. Some cases are caused by irritation of the prepuce, the urethra 
and possibly the prostate which stimulates the nerve centers connected 
with these regions. The sporadic practice cannot be held in abhorrence 
although it is not to be encouraged. No serious mental or physical 
damage has even been demonstrated except in habitual and confirmed 
cases. Habitual performance of the act continued into adult life may 
lead to difficult adjustment of married relations. Some authorities 
claim that masturbation may continue along with normal heterosexual 
relations; but this notion, along with the other notion that it produces 
debility, and insanity cannot be held too seriously. Berne (518) holds 
that masturbation is no more common among psychiatric cases than 
among the normal population. When it occurs, he believes that the 
therapist should adopt a reassuring attitude, since the problem is usually 
solved by eventual heterosexual relations. Continuation of the practice 
is a symptom of marital maladjustment rather than a cause. The cure 
of this habit is one that cannot be undertaken by the lay person, and 
should not be attempted. 3 

Homosexuality is the amorous desire for a person of the same sex and 
the amorous stimulation of a person of the same sex. The analysts 
hold that this is the second stage of normal sexual development. This 
is a fallacious notion since we have no proof that the majority of indi- 
viduals pass through this period. Where the analysts tend to confuse 
the average reader is in the loose usage of the term homosexual. They 
apply it to any type of interest manifested by individuals of the same 
sex toward each other. Theoretically, then, any boy or girl who has any 
affection for a man or a woman is manifesting a homosexual tendency. 
All of us are homosexual according to this theory since we have group 
activities involving members of the same sex, such as clubs, schools, etc. 
It is ridiculous to call this behavior homosexual since no element of the 
amatory or reproductive desire is present. If these relations are to be 

3 The readers are referred to Habits: 'Their Making and Unmaking, by Knight Dunlap, 
for a more detailed account of the habit. 


considered as homosexual, then they are highly commendable and an- 
other term should be substituted which does not have such an undesir- 
able connotation. 

The term homosexual should be applied strictly to those practices in 
which the sex processes are definitely stimulated. These activities, 
while undesirable and harmful in many cases, cannot be said to be 
abnormal when engaged in sporadically. Kinsey (519) reported that 
37 per cent of males have had some kind of homosexual experience and 
that the incidence is higher among males unmarried until the age of 35. 
Wheeler (520) found that among 100 patients of an outpatient psychi- 
atric clinic (age range about 18-35) tnat homosexuality occurred as 
part of the problem in at least 50 per cent of the cases. The figures of 
Kinsey, Wheeler and Gardner agree fairly closely and seem in part to 
substantiate the Freudian viewpoint that homosexuality may be one of 
the stages of sex development. Kinsey stresses, however, the environ- 
mental and cultural factors in determining homosexual trends. The 
habit is quickly established when once initiated, and the means of its 
spread is through teaching. Its prevalence in the army, in schools, and 
other social and business organizations is usually the result of instruction 
from other individuals. It arises also because of the paucity of other 
means of outlet of the amatory desires. When once established, it re- 
sults in the inability to adjust successfully in normal heterosexual 

The best preventive is to avoid contacts that are likely to lead to the 
habit. Beware of the older individual of the same sex who exhibits be- 
havior toward you which you would likely exhibit to a member of the 
opposite sex. Avoidance of sleeping in contact with members of the 
same sex is also desirable since this may unintentionally lead to this 
practice. Acting roles of members of the opposite sex leads, through 
ideational processes, to the practice in a few cases and should be indulged 
in only with extreme caution. 

Intimate association with members of the same sex is necessary since 
many of our most valuable character attributes are formed in this man- 
ner. Beware, however, of the individual who is too solicitous, who 
displays jealousy of you or who attempts to make you obligated to him or 

Other theories have been offered for explaining this abnormal form of 
behavior. The one mentioned earlier by the analysts holds that it is 
an arrested stage of development of the sex instinct. Gardner's study 
(521) on the relation between paranoia and homosexuality is quite 


interesting in view of the Freudian contention that delusions of persecu- 
tion in paranoia are due to unsuccessfully repressed homosexual 
tendencies. Gardner examined 120 consecutive admissions to a mental 
hospital all of whom were diagnosed as paranoid dementia praecox or 
as paranoid condition. He assumed the presence of homosexual drives 
if the patient had made homosexual attacks; if his delusions indicated 
that he was being attacked by others; or if his symbolisms showed 
unmistakable signs that his delusions had such a basis. It was found 
that in 45 per cent of the cases there were evidences that homosexual 
trends were in existence. Page and Warkentin (522) found that on the 
Terman-Miles Masculinity-Feminity Test paranoid men tend to respond 
like women and hence may be of the passive homosexual type. While 
these studies point to a relationship between the two conditions, they do 
not throw light on the mechanisms involved. Other theories hold that 
perverts of this type tend to have physical and mental characteristics of 
the opposite sex due to improper glandular development. There may 
be some truth in this statement since the behavior of animals can be 
modified by injection of hormones of the opposite sex. This will not 
account, however, for many of the cases and especially those who are 
initiated into the habit. Unpopularity with the same sex may lead to 
the assumption of characteristics of the other sex and into homosexual 

Thorpe and Katz (523) have summarized the Freudian point of view- 
in a very succinct manner and their summary is quoted in the following 
section: 4 

"The psychoanalytic explanation of homosexuality is based on several factors. In 
men, a major factor is considered to be the influence of an earlier strong castration complex. 
In this regard Fenichel suggests that the thought of being without a genital organ is so 
terrifying that it may cause the individual in question to avoid any sexual relationships 
with a member of the opposite sex. Another etiological factor is the Oedipus complex. 
His strong emotional attachment to his mother has brought the now mature man to behave 
like her. He thus chooses as love-objects men (like himself) and treats them with the same 
fondness with which he had been treated by his mother. In some instances a man who, as 
a child, had no mother (or had a cruel and severe mother) may become overly attached to 
his father and thus predisposed toward seeking persons who resemble his father; in still 
other instances a cruel and severe father may have caused the individual to feel hateful 
and resentful toward him. This hostility is repressed because of guilt feelings, and the 
boy thus tends to show love for persons like the father. 

In women, the process of homosexual development is similar to that in men. Ac- 
cording to Fenichel, 'The sight of a (male genital organ) may create a fear of impending 

4 Thorpe and Katz. Reprinted by permission from The Psychology of Abnormal 
Behavior, Ronald Press Co., 1948. 


violation; more frequently it mobilizes thoughts and emotions about the difference in 
physical appearance. These fears, thoughts, and emotions may disturb the capacity for 
sexual enjoyment to such a degree that sexual pleasure is possible only when there is no 
confrontation with a (male genital organ).' In some instances girls who were overly 
attached to their mothers regress to this early childhood pattern after unpleasant or un- 
favorable experiences with men in adolescence or adult life. In cases where the mother 
was cruel or severe, the repressed hostility and ensuing guilt feelings can give rise, as in the 
case of men, to a 'love for persons like mother.' " 

The cure of this disorder is impossible unless the individual definitely is 
desirous of being cured. In the first place, detection is difficult and sec- 
ondly the tendency to relapse is too great. Various methods have been 
tried, such as advising heterosexual indulgence which results in only a 
still graver condition. Hypnosis will cure some cases, but not others. 
The method outlined by Dunlap for curing stuttering has been success- 
fully applied in some instances. 

Fetishism is accompanied by an abnormal interest in objects associ- 
ated with a person of the opposite sex and the desire for stimulation by 
those objects. The range of fetishisms runs the gamut from repeated 
reading of letters to collecting pieces of clothing or other objects identi- 
fied with the opposite sex. The term has been used to include a much 
wider range of associated materials by some writers. It has been used to 
include the worship of idols, rituals and various other types of worship 
impelled by fear. At the present its use will be restricted to association 
with the amatory desire. There is a certain amount of normal interest 
which must not be construed as abnormal. It is only when the fetish 
assumes the proportion that it inhibits the usual processes of the amatory 
desire that it belongs in the latter category. 

The development of this condition comes about through strictly psy- 
chological processes, especially in those cases where the ideational fac- 
tors are sufficiently strong to arouse the sexual processes. Fetishism is 
considered by some theorists to be a defense against fear of being re- 
jected by a member of the opposite sex, hence the substitution of an 
object that cannot reject or a part of the body against which there is no 

Sadism is a term identified with the hurting of or injury of the person 
who is the object of the individual's amatory desire. Masochism is the 
desire to be hurt or made to suffer by the person who is the object of the 
amatory desire. The ramifications of these sexual perversions are to be 
found in religious sacrifices, persecutions, self-mutilation, penance, 
martydom, and meekness. Although these may be the result of other 
desires, these actions are sometimes included in this group. There is no 


sharp line of demarcation between the normal tendencies and the abnor- 
mal tendencies, since in courting, sadistic tendencies show up from time 
to time. For example, the young woman may very much desire a date, 
but refuses it since she will thereby make her suitor suffer. In some 
pathological cases, the masochist must be insulted, whipped or injured in 
order that he or she may become sexually excited. 

It was stated earlier that the pattern of the amatory processes is 
quite variable; it is highly probable that these attempts to injure and 
to cause suffering reproduce some parts of the pattern which are usually 
involved in the amatory processes of the individual but which are 
relatively unimportant for the average person. 

Various theories have been formulated for explaining these aberra- 
tions. These are summarized briefly in the following section: 


(1) Results from conflict over sex matters. Early condemnation, 
prohibition and shame surrounding anything sexual inculcates attitude 
of disgust and shame for heterosexual relations. This causes avoidance 
and fear of such relationships. This fear results in hostility and aggres- 
sion and the individual inflicts pain and injury upon the object that 
creates fear, disgust and shame. 

(2) Results from insecurity arising from parental rejection and loss 
of parental love. Love object is identified with parent or parent figure 
and hostility is vented on such figure as compensation for hostility 
toward early life situation. 

(3) Results from castration complex. Fear of loss of genitals is over- 
come by inflicting pain on others. If individuals are powerful enough 
to inflict punishment on others they need not fear infliction of punish- 
ment on themselves. 


(1) Results from conflict over sex matters. Early training arouses 
disgust and shame over sex matters. Since shameful and disgusting 
activities are punished, the individual resorts to self-punishment. Pun- 
ishment allows the individual to gain self esteem since it proclaims his 

(2) Results from feeling of inferiority. The individual gains superior- 
ity over sex partner by demonstrating his ability to take punishment. 

(3) Results from attempt to gain affection and love. The individual 
will tolerate humiliation and punishment to gain love or please his sex 


Exhibitionism and voyeurism are forms of sexual behavior engaged in 
by most normal people to a limited degree. The first type of behavior 
refers to exhibiting the sexual organs and the second type refers to in- 
specting the sexual organs or the secondary sex characteristics of the 
opposite sex. When this behavior is indulged in for the purpose of 
attaining sexual gratification to the exclusion of the other usual com- 
ponents of gratification it may be considered abnormal. Both of these 
aberrations are considered by the psychoanalysts to be defenses against 
inability to handle a threatening ego situation. Exhibitionism may 
arise because of feelings of inadequacy in sexual power. The individual 
overcomes this inadequacy by exhibiting the sex organs, thus restoring 
his confidence in himself. Another approach along similar lines lies in 
the basic fear of castration. Such fear is overcome by reassurance ob- 
tained by looking at the sex organs, which gives confidence that they are 
still present. Voyeurism or inspectionism arises out of a somewhat 
similar situation. The individual feels a fear of failure in heterosexual 
relations and protects himself or herself against this fear by simply 
looking at the opposite sex. They gain mastery over the opposite sex 
by this method but do not subject themselves to possible failure. The 
Freudians assume that by the process of looking they incorporate the 
other individual, thus identifying themselves with the other person and 
thereby gaining mastery over them. 

Inspectionism arises in children as a result of curiosity in attempting 
to discover the functions of various parts of the body and may continue 
well into adolescence. Sex excitement may be engendered normally by 
this activity and as such cannot be construed as abnormal. 

Zooerasty (bestiality), necrophilia (technically, love for dead bodies 
but by general usage sexual relations with dead bodies) and pederasty 
are perversions in which the object of the amatory desire is an animal, a 
cadaver, or a child respectively. 

Part of the confusion in the use of these terms has arisen because they 
have been applied strictly to one phase of the amatory process in some 
instances and to the lay usage of the term "love" in other instances. 
Normal mental development is an important factor in many of these 
cases. The maladjusted individual cannot compete with other normal 
individuals because of his enfeeblement. In cases of normal mentality, 
the usual outlets for the amatory desires are markedly cramped and the 
amatory desire is directed to the object or objects that offer least resist- 

Kinsey and his co-authors (524) in their survey have found what has 
been generally suspected, that bestiality occurs most frequently in the 


rural areas. There is a paucity of normal heterosexual outlets and an 
abundance of animal outlets. This practice is probably more prevalent 
among males than among females, although there are records of females 
engaging in sex relations with animals. Very little is known about the 
psychological factors in the three conditions mentioned above, but 
psychopathological conditions, such as mental deficiency, senile de- 
terioration, psychopathic personality, are often encountered as con- 
comitants. Popular superstitions among certain classes of the popula- 
tion concerning the effectiveness of these forms of sexual activities in 
curing venereal disease will also account for a certain number of cases. 


The parental desire is the outgrowth of several of the other fundamen- 
tal desires. It must not be confused with the reproductive and amatory 
desires since these may function entirely separately. The usual se- 
quence of the desires mentioned arises in somewhat of a chronological 
order. The reproductive desire may arise through preeminence or con- 
formity in that either of the two sexes may wish to demonstrate that they 
are capable of bearing offspring. The parental desires per se have 
nothing to do with the physiological processes involved but center in 
the desire to possess and care for children. This is clearly shown in the 
activities of young children, who play the role of parents before the ama- 
tory desire develops. Since the parental desire is so uniform throughout 
the species, it seems feasible to list it as one of the fundamental desires. 
This desire may be modified in numerous ways. It may normally result 
in the adoption of children other than one's own; or the object of the de- 
sire may take the form of animals, dolls, or other helpless creatures. 
Deficiencies of the desire result in destruction of the offspring in animals 
and sometimes in humans It is usually assumed that the parental 
desire of the male is weaker than that of the female, since in many of the 
lower animals the male destroys the offspring. In other animals the 
offspring is fed and guarded by both sexes. In mammals, the female 
must play the dominant role, since the mother nurses the young for a 
period of time. However, in humans we have no data to show that the 
parental desire is stronger in one sex than in the other. One perversion 
of the parental desire is technically called zoophilia. The difficulty in 
distinguishing between a normal interest in animals and an abnormal 
interest (zoophilia) is quite obvious. Interest in animals may exist 
along with non-modified parental desire. For example, among certain 
Malay tribes, women nurse pet pigs when they are nursing their children. 
Likewise civilized humans may have a keen interest in animals along 


with a strong parental desire. The chief danger lies in the fact that the 
interest in animals may influence the direct manifestation of the parental 
desire, in that the processes may be sufficiently activated by these means. 
Women or men who lavish excessive care and attention on cats, dogs, 
or other animals may be suspected of substituting these objects as a 
means of satisfaction for children. 


The general attempt on the part of man to excel or stand apart from 
his fellow man is noticeable in all races of men both in history and at the 
present time. The ways that are adopted for accomplishing this pur- 
pose are so numerous that only a few examples can be given. An indi- 
vidual may desire to be outstanding in religion, politics, education, medi- 
cine or in any profession. Other individuals may gain preeminence 
through athletic prowess, ability to drink, notoriety in the press, dressing 
in latest fashions, being hated or being humble. The appet underlying 
this desire is still unknown, and consequently there may be some question 
as to its authenticity as a primary desire. This desire has features that 
are in keeping with the postulates of Adler concerning the lure of 

Perversions of the desires for preeminence are very numerous. Ad- 
ler' s notion of the influence of organ inferiority on the will to power or 
superiority can readily be ascribed to perversions of the preeminence 
desire. It is possible that the actual organic basis of this desire lies in 
morphological development as Adler suggests. A physical defect may 
determine the direction of the manifestation of the desire for preemi- 
nence. Speech difficulties, blindness, deafness, or deformity may lead 
individuals to quite diverse kinds of behavior. Mental status, social 
standing, and economic standing will also play an important role in the 
whole situation. The paranoid may have his desire so modified that it 
is satisfied by ignoring facts. He becomes in his own mind the wealthiest 
man in the world, a great scientist, an inventor or some great historical 
character such as Jesus, Napoleon, Queen Victoria, or Lincoln. This 
form of activity compares with the usual activity of normal adults who 
derive vicarious satisfaction of their desires by identifying themselves 
with superior people or belonging to organizations which they feel are 
prominent organizations. Similarly, children are wont to satisfy their 
desire for preeminence by praising their parents or possessions. 

In other cases the desire may be modified in a different way. The in- 
dividual achieves satisfaction by thinking that he is worthy of merit but 


that it is withheld through lack of appreciation by the group or specific 
groups. This general notion gives rise to delusions of persecution coupled 
with paranoid tendencies. Such an individual believes that he has been 
singled out by the group, and as a result he is oppressed by spies of 
the church, government, lodge, or his family who constantly harass 
him. Counterparts of these individuals can be found almost daily 
among so called normal people. They constantly blame others for their 
failures, insist that their failures are due to bad luck or to the fates. 
Individuals who believe that they merit promotion but whose promotion 
is withheld for lack of merit and individuals who always insist that the 
appointment which they kept at the wrong time was the mistake of 
some one else, are exhibiting tendencies of this kind. 

Some perversions arise because of disappointment in securing preemi- 
nence through useful activities. In spite of the fact that the individual 
may possess beauty, be intelligent, or have wealth, these do not suffice 
since many other people have the same things. Ordinarily we might 
expect cultivation of these traits, and in many cases only these forms 
of securing attention are employed. The woman with a good figure 
attempts to display it and lavishes care on it. She may give special atten- 
tion to the selection of clothing to show it off. The individual who pos- 
sesses wealth may buy expensive cars or jewelry, and still another indi- 
vidual may recount his exploits to demonstrate his superior intelligence. 
When these usual outlets do not secure the recognition desired, reversion 
to unusual forms of activity occurs. Hobbies such as collecting canes, 
pistols, stamps, cigar bands, steins, china, clocks, and similar objects are 
engaged in because they make a showing. These are normal modifica- 
tions of the preeminence desire which may become exaggerated. 

Sometimes the modification of the preeminence desire takes the form 
of motor conspicuousness which is objectionable or annoying. This 
form of perversion includes exhibitionism, display of vanity, bizarreness 
in dress, loud speech in groups, stunts in public, and even unusual forms 
of murder. Exposure of anatomy on the stage, at the seashore and to a 
certain extent on the street for the general purpose of arousing the 
amatory processes of the opposite sex is not usually called exhibitionism. 
Exhibitionism is deriving satisfaction through exhibiting the sex organs. 
This form of behavior is more prevalent among men than women. It 
is part of the amatory process and is instigated to call attention to 
anatomical features usually concealed. Vanity is displayed by primp- 
ing, by strutting in lobbies or before mirrors. Similarly, bizarreness in 
dress, boisterous or loud speech, and attracting attention in public by 


any unusual activity are encountered on occasion in non-psychotic 
individuals, but in general, they are indicative of slight mental aberra- 
tion. The so-called scientific murders, the planning of super crimes 
and their execution, especially when money is no consideration, are 
of the same type. 

Becoming ill is a form of behavior that frequently goes over into an 
abnormal variety. Every one is familiar with the youngster who does 
not feel well as soon as he is not the focus of attention. The woman who 
likes to tell of her numerous ailments and the individual who speaks 
about his affliction that baffles all the physicians are trying to secure 
attention. In some cases, these individuals become wards of psycho- 
pathic hospitals and are called psychoneurotics. Habit has undoubtedly 
played a large role in the etiology of their difficulties. 


This is the desire to belong to a group and to share in the group con- 
sciousness and group feelings. It is fundamental for social psychology 
although its ramifications are more difficult to trace in individual be- 
havior. The appet of this desire cannot be localized with our present 
knowledge. Examples of the normal operation of the desire are shown 
by all social groups. Modifications exist to a certain extent in hermits, 
tramps, and in individuals who isolate themselves in so far as possible. 


The desire for activity and the desire for rest may be viewed reason- 
ably as two phases of a single desire for which no adequate name is avail- 
able. Practically, a state of equilibrium is never reached between these 
two desires, since the physiological state of the muscles is constantly 
changing. In one state of the muscles, the desire for rest occurs. The 
appet for these desires may be localized tentatively in the muscles. 
Activity or rest may proceed upon initiation without the ideational proc- 
esses although rest is more likely to take place under these circum- 
stances than is activity. 

The activity desire is less influenced by other desires in children since 
food, shelter, and the sex desires are satiated with little effort or else have 
not assumed a prominent position in the galaxy of desires. The activity 
desire itself needs further discussion and can be treated independently 
of the desire for rest. It has been stated previously that activity may 
be initiated and may occur under the influence of the appet alone. The 
question, then, that has to be answered is what is the general condition 


of the organism ? Various theories have been advanced to explain this. 
They have been developed primarily upon the basis of what happens to 
a muscle or the nerve innervating it after it has been active. Increase in 
available glycogen, increase in the blood sugar level or a chemical change 
in the neural structure have all been assigned as possible interoceptive 
or proprioceptive stimuli. The actual condition may be localized in a 
specific muscle group or non-localized, resulting in general feeling of well 
being and possibly euphoria. Richter (525) and Smith (526) in their 
work on monkeys and guinea pigs have shown that the frontal lobes 
function in the mediation of activity. Removal of the frontal areas 
of the cortex results in a significant increase in activity. Although the 
appet contributes to the desire, the more important aspect of the desire 
remains to be explained. 

The type of activity engaged in for the satisfaction of the desire will be 
controlled to a large extent by ideational factors and the relative inten- 
sity of other desires. In fact, the activity desire may arise in adults by 
way of the desire for food, protection, etc. It is difficult to think of 
any type of activity of adults that cannot possibly be explained on a basis 
of satisfying one of the other primary desires. Playing golf, gymnastics 
and walking may be attributed to the desire for preeminence or to the 
amatory desire. By these methods, the individual wishes to excel in 
physical fitness. If babies or animals are observed, however, it can be 
seen readily that they engage in activity. Babies constantly make many 
random as well as semi-coordinated movements. Rats will exercise 
voluntarily in revolving cages even though they are bountifully supplied 
with food and water; likewise they will exercise either in isolation or when 
maintained in groups. The factors influencing activity have been most 
carefully studied with rats. Diet, water, atmospheric condition, age, 
sex and the estrus rhythm play important roles in the amount of activ- 
ity taken. Casual observations on humans tend to substantiate the 
inferences that may be drawn from animal experimentation. Modi- 
fication of the desire for activity results in increased activity, decreased 
activity and inimical forms of activity. The difficulty of determining 
whether the modified activity is a direct result of the desire for activity 
or whether the activity results from some abnormality of another desire 
is tremendous. The marathon runner is certainly not manifesting an 
abnormality of the desire for preeminence. It is probable that some 
manics have an excessive desire for activity. Whether the nature of the 
excess is ideational or due to the appet is not known at present. In 
Graves' disease (exophthalmic goiter) excess activity may be shown. 


The symptoms of this disease are characterized by nervousness, tachy- 
cardia, tremor, and sometimes emotional disturbances. These symp- 
toms seem to stimulate further glandular activity which in turn aggra- 
vates the symptoms so that a vicious circle is established. Fortunately, 
this disease can be adequately controlled by proper medical treatment. 
In some of these cases, at least, the appet seems to be weak since medical 
treatment will partially alleviate the condition. The administration of 
carbon dioxide and the use of colloids produce at least temporary im- 
provement in some psychopathic patients. Similarly some obese indi- 
viduals show a lack of the desire for activity. The appet may be affected 
since the muscles may be weakened by the increased demands to supply 
the fatty tissue. On the contrary, ideational factors may inhibit the 
desire since these individuals are not usually graceful in their muscular 


The appet for rest is undoubtedly a condition of the muscles. Where 
the initial action occurs is still conjectural. Some authorities ascribe 
fatigue to using up the available glycogen in the muscles, others to 
the freeing of lactic acid and still others to various toxins manufac- 
tured during the process of muscular activity. Theories have been 
based on the circulation of toxins in the blood stream which in turn 
change the resistance at the synapses or produce some change in the 
nerve cell itself. Evidence can be furnished in support of all these theo- 
ries. In spite of the divergence of views held concerning the actual 
causal factor, all of the theorists agree that the causal agents are removed 
by rest or quiescence and during sleep. Physical rest and so called men- 
tal rest are desired quite independently of each other which complicates 
the analysis of the appet for the desire. If the view is taken that motor 
responses are always involved in thinking or ideation, then the postula- 
tion that different sets of muscles are involved will have to be made. 
If mental fatigue involves only fatigue of neurons, then the innervation of 
muscles cannot be explained, or the assumption must be made that the 
neural pathways involved in thinking differ from those employed in 
physical exercise. The evidence on this point is clear cut since mental 
fatigue seems to be dissipated through physical activity. Experiments 
by Gray (527) on animals bear out the contention. He exhausted 
rats by forcing them to run in cylindrical cages until they could scarcely 
stand and then tested them on maze learning. These animals showed a 
slight superiority to non-fatigued animals. Nicholson's (528) work 


with hypnotized subjects indicates that different central neural path- 
ways may be involved in innervating the same muscular response since 
fatigue produced under hypnosis was only partially carried over into 
the normal state and vice-versa. Ideation and the spread of the other 
desires markedly influence the rate of fatigue and the desire for rest. 
Experiments have shown that factory workers tire at about the same 
time of day, regardless of the number of hours that have elapsed since 
beginning work. Rats show similar tendencies in the time at which 
they are most active. Everyone is familiar with the fact that one's de- 
sire for sleep conforms to well-established habits. These habits of feel- 
ing tired or desire for rest can be altered with slight motivation. Mone- 
tary compensation for long work, or fear of punishment will readily 
overcome the usual onset of fatigue. The explanation offered is that 
reserve energy which is not usually utilized is expended. 

Recovery from fatigue normally is brought about through metabolic 
processes which are capable of meeting the requirements of activity. 
In some instances, however, the rate of recovery is slower than the rate of 
fatigue and a chronic condition ensues or exhaustion sets in. Under these 
circumstances, undue pressure may be put on various vital parts of the 
organism and result in a general breakdown. Fortunately, the desire 
for rest intervenes in most instances before any serious damage is done, 
and the organism is restored. There is such a wide variety of diseases 
which affect the appet, i.e., increase the desire for rest or induce unusual 
fatigue that it is impossible to go into these in detail. Malnutrition due 
to faulty metabolism, febrile diseases, local inflammatory conditions and 
dys functioning of the special senses are sufficient causes to produce the 
effects previously described. Endocrine dysfunction plays a prominent 
role in the desire for rest. The injection of adrenalin, ephedrine and 
extract of adrenal cortex act as partial antidotes to fatigue, and the in- 
ference might be made that lack of products similar to these may favor 
the onset of fatigue. The hormones of the sex glands have been shown 
to be influential. Castrated male rats and ovariectomized female rats 
decrease their voluntary activity. Huhner (529) has emphasized the 
importance of prostatic irritation and disorders of the sexual function 
in some neurasthenic and psychasthenic patients. He attributes the 
sexual disorders related to these mental diseases as being due to exhaus- 
tion of the neural centers. 

The action of benzedrine, amphetamine, pervirtin on overcoming the 
effects of fatigue have been studied. Alwall (530) (531) showed that 
soldiers fatigued by three nights of prolonged marching with little 


intervening sleep during the day did not have the subjective symptoms 
of fatigue when given 20 to 30 mgm. of benzedrine or 18 mgm. of 
pervirtin. Rudolph (532) administered amphetamine to fatigued and 
depressed individuals and found that the substance tends to remove 
fatigue and the less severe depressions. There was an increase in self 
confidence and hope, although there was some tiredness following the 
amphetamine periods. The duration of the beneficial effects varied 
for individuals. Pemphigmus produces a depressive influence on maze 
behavior, rope walking, and climbing in rats, according to Macht and 
Insley (533). Pemphigmus serum injected into rats seems to cause an 
invasion of the central nervous system and this disease should be viewed 
as having a more extended effect than the mild dermatitis exhibited. 

The ideational factors which tend to bring about abnormalities of the 
desire for rest are usually centered in vague fears and anxiety. The 
anticipatory thinking may have in some instances a factual basis, that is 
some organic difficulty may have existed. In some cases, after the 
organic difficulty has been removed, the individual persists in resting in 
spite of the fact that rest is not needed. Invalidism has been explained 
by many authorities as the individual's failure to adjust to environmental 
factors, such as marriage, home and working conditions, as well as to 
other desires. Menninger (534) contends that rest is much abused in 
psychiatric situations. Complaints of overexertion are symptomatic 
of illness, rather than the cause. 

Hollingworth's redintegration theory, and Hurst's inattention theory 
present the theoretical bases necessary to explain such behavior. Neu- 
rasthenia, anxiety neurosis and psychasthenia are recognized clinical 
disorders, the etiology of which may be attributed to disorders of the 
desire for rest. The clinical symptoms presented by patients of these 
types resemble actual fatigue or exhaustion states. The organic condi- 
tions which accompany true fatigue are lacking however. Memory of 
previous fatigue may be the cause since in most of these patients a 
history of physical illness may be found. Sherry's (535) work shows 
that these patients when properly motivated are capable of doing tasks 
requiring sustained efforts. Their work curves in. gripping a dynamome- 
ter and tapping are comparable to those of normal individuals. The 
outstanding feature of these clinical types is the marked difference be- 
tween the appet and their anticipatory thinking. Some of the patients 
think that the slightest activity will exhaust them, while the facts show 
that they are quite capable of indulging in normal physical and mental 
activity. Even normal people show a wide discrepancy between their 


subjective fatigue estimates and the actual amount of work done. We 
have very poor tests for measuring the extent of fatigue or recovery from 
it. Brozek and Keys (536) have attempted to use flicker- fusion fre- 
quency as a sensitive measure for fatigue. The found, however, that 
such frequency is at best only a very gross measure. Further discussion 
of these cases will be presented in a later chapter. 


Feelings and emotions are experiential facts. They are comparable 
to sensations in that they are initiated by stimulation of receptors and 
terminate in response. Feelings are usually distinguished from emo- 
tions in that they are more complex particularly with reference to the 
content of the conscious experience. A few examples may enable the 
reader to comprehend the relation between sensation, feeling and emo- 
tion. If sugar is placed in the mouth, the sensation of sweet may occur 
as well as a feeling of pleasantness. If music is heard, the sensations are 
of tonal qualities and the feeling aroused may be unpleasantness. The 
student who asks the instructor for his grade at the end of the term and is 
told that he has been loafing and shows little promise as a student and in 
addition has failed, will have the auditory sensations of the words spoken, 
a probable feeling of depression and possibly an emotion of anger. The 
essential characteristics of feeling are its vagueness and lack of localiza- 
tion. It lasts for a considerable period of time after the disappearance 
of the stimulus; and it is not localizable in space nor can it be referred to 
body surface as in the case of sensations. The receptors are usually 
said to be free nerve endings in the viscera and soma. The viscera are 
probably the most important source of feeling, and consequently the 
afferent autonomic system is the vehicle for the sensory system. In- 
cluded in the afferent system are nerve terminals in the skin, striped 
muscles, the mesenteries, peritoneum, the connective tissue of the heart 
and blood vessels, esophagus, stomach, intestines, kidneys, bladder, and 
generative organs. The afferent current derived from these sources 
must go somewhere and must produce important effects. The effects 
produced may be activity of the striped muscles, particularly if percep- 
tual and thought reactions are involved, or they may be glandular or of 
the smooth muscle variety. If these latter responses predominate, the 
efferent part of the autonomic system is involved. 

The method of connecting afferent impulses with efferent impulses 
has been the source of much controversy. The view generally held 
at the present time is that the appropriate cortical sensory area 


must be intact. In addition, a portion of the thalamus must be 
intact; otherwise there is a loss of affective experience or incoordi- 
nation between the affective experience and the response. The im- 
portance of the thalamus has been emphasized by the work of 
Bechterev, Goltz, Dejerine and Roussy, Head, Gushing, Cannon 
and others. 5 Bechterev (537) showed that transection of the region of 
the thalamus results in almost complete abolition of the characteristic 
emotional response in dogs, whereas deprivation of the cerebral hemi- 
spheres left these responses intact. Under the latter condition, painful 
stimulation in the region of the face evoked snarling and retraction of 
the corners of the mouth. Stroking of the back produced the usual 
pleasant responses including, in some instances, tail wagging. Goltz 
(538) removed both hemisphere? of a dog and observed his behavior for 
a period of approximately eighteen months after the operation. A wide 
variety of stimuli, including both those that would invariably arouse 
anger or rage and those that would not, produced excessive overt 
behavior characteristically associated with excitement or anger and 
rage. Handling by the experimenter or running against an object were 
adequate for invoking the response. Goltz felt that the tendency to- 
ward activity or excitement was much stronger than the tendency to 
exhibit peaceful behavior characteristic of quiet or pleasant feelings. 
Cannon and Britten (539), and Bard (540) have noted the behavior of 
cats following cortical ablation. These animals retained the motor 
activities usually exhibited when defending themselves or when they 
are restrained by mechanical means. Erection of the hair on the tail, 
extension of the claws, lashing of the tail and disturbance of respira- 
tion and breathing were observed. Harlow and Stagner (541) give 
accounts of cases by Marchand and Chatagan and by Roussy and 
Lhermette. The former report a case in which phobias, anxiety and 
depression occurred with an involvement of the hypothalamus. The 
latter report the case of a girl who, prior to the onset of the neural 
involvement of the tuberian region, had been active and gay but who 
became suicidal, withdrawn and taciturn. Feuchtwanger, (542) in his 
extensive study of frontal lobe injuries, indicated that changes in feel- 
ing and emotions are likely to occur unless the connections between the 
thalamus and cortex are intact. Head and Holmes, (543) in comparing 
patients with optic thalamus lesions, observed that cortical lesions pro- 
duced inability to make two point discrimination, thermal discrimina- 

5 For a more extended treatment of feelings and emotions, the following books are sug- 
gested. James and Lange: Emotions. Psychology Classics, 1922; Wittenburg Symposium: 
Feelings and Emotions > 1928; BeebQ-Cenjer: Pleasantness and Unpleasantness , 19^2, 


tion and partially destroyed kinesthetic sensations. Pain and touch 
sensibility were left intact or reduced only slightly. Thalamus lesions 
produced, on the contrary, practically no disturbances of sensation. 
There was an excessive response to affective stimuli. Any sensory im- 
pulse strong enough to arouse consciousness would produce over loading 
of affective response. Those patients in whom the lesion affected only 
one half of the body gave a greater response on the side affected by the 
lesion in spite of the gross loss of sensation. There was marked dis- 
crepancy between the manifestation of both pleasant and unpleasant 
feelings and the sensations derived from the stimuli. For example, if one 
half of the face was involved, a pin prick on that half gave rise to behavior 
characteristic of extreme unpleasantness, whereas on the uninvolved side 
no observable behavior could be detected which would be indicative of 
unpleasantness. The application of warm objects to the affected areas 
produced feelings of pleasantness which were observable by the behavior 
of the individual. These same stimuli produced a marked response on 
the unaffected area. In general, it may be said that loss of the cerebral 
hemispheres does not deprive the animal of ability to show expressive 
behavior of feelings, while loss of the thalamus deprives the animal of 
expressive behavior characteristic of pleasantness and unpleasantness. 
That the cortical areas exert a mediating influence on the activities of 
the thalamus can be readily ascertained from the studies of Moniz 
(544). Freeman and Watts (545), and Rees (546) have performed 
prefrontal leucotomy (division of fibers connecting the frontal lobe with 
the thalamus) as a means of relieving psychotic symptoms. In patients 
suffering from anxiety due to mental conflict, groundless fears, suicidal 
tendencies, self-mutilation, destructiveness and violence, severance of 
fibers connecting the prefrontal lobe from the thalamus may entirely 
relieve many of these symptoms. Those cases in whom delusions are 
well organized may be relieved of their worries and tensions associated 
with the delusions even though the delusions remain. The prefrontal 
lobes then may be regarded as playing an important role in emotions. 
The neural bases of emotional response cannot be said to be of more 
significance than the psychological functions involved. The question 
that needs consideration is whether emotional responses are native, 
that is instinctive, or are they learned and do they become habitual? 
For example, do cats arch their backs, spit and lash their tails when 
confronted by a dog, without learning? Does the human weep and feel 
sorrowful at the death of a relative except through a long process of 

Watson's (547) early experiments with infants led him to conclude 


that there were three innate patterns of emotional response present at 
birth; (a) love, which included behavior such as gurgling and cooing, 

(b) fear, characterized by catching the breath, grasping and crying and 

(c) rage, manifested by movements to free the organism and move- 
ments somewhat similar to those in fear. The validity of these patterns 
as indicative of emotional response has been attacked by the work of 
Sherman (548) who found that competent judges could not agree on 
the nature of the emotion portrayed nor the stimuli which probably 
produced the responses. The work of Pratt, Nelson, and Sun (549) 
and of Bryan (550) indicates that these so-called emotional responses 
are parts of the complete repertoire of the infant and that there is a high 
probability that the responses are common to many other varieties of 
stimuli which do not involve the emotions set forth by Watson. Char- 
acteristic patterns of response are probably built upon experience but, 
even in adults it is hazardous to guess the specific type of emotion ex- 
hibited. Many experimenters have attempted to analyze the emotions 
from facial expression. In general the ability to judge portrayed emo- 
tion is fairly accurate although most of the early experiments were made 
with simulated emotions. Ruckmick (551) and Dunlap (552) have offered 
evidence that the lower part of the face is more important in portraying 
emotions than the upper part. The work of Brunswick (553), Totten 
(554), Landis (555) and Duffy (556) indicates that changes in metabo- 
lism, smooth muscle tonus, striped muscular tension, blood pressure, 
and skin resistance are not adequate criteria for differentiating the emo- 
tional response pattern. Almost all of these functions tend to be in- 
volved in a wide variety of responses, and all of the emotions have in 
common a wide variety of such responses. The details of the pattern 
for the particular emotion have through experience become identified 
specifically, but even then the interpretation may be erroneous. 

The inference may be made from a study of feeblemindedness by 
Morrison (557) that emotional development is a complex process not 
definitely linked with physical or physiological maturity. He recorded 
the behavior of various grades of feeblemindedness and felt that there 
was a positive correlation between the appearance of anger and affection, 
and intelligence. Fear, on the contrary, gave no significant correlation. 
He surmised that this was due to the protected life in the institution. 
Similarly, the appearance of emotions showed no correlation with chron- 
ological age. Maturation, alone, then is insufficient to account for the 
complex emotional responses. 

Stratton (558) and Landis, Ferrall and Page (559) have shown that 
the expression of fear and anger is in part determined by general ohvsio- 


logical condition. Individuals who have histories of numerous diseases 
(other than endocrine) are likely to have a greater number of fears and 
to become angry in more situations than people relatively free from 
history of disease. These studies indicate that many diseases influence 
endocrine balance which in turn influences the expression of emotion. 
Rowe and Pollock (560) and Hoskins and Sleeper (561) have studied 
indirectly the influence of endocrine dysfunction on emotion. They 
have found the incidence of endocrine dysfunction much higher among 
groups of psychotics and psychoneurotics than among normal people. 
Since emotional disorders are prevalent in many of the psychotics, we 
can safely say that endocrine dysfunction is a potent factor. It is, 01 
course, unwise to conclude that the individual will develop an emotional 
disorder simply because an endocrine dysfunction is present. Psycho- 
logical factors, in addition to the hypo- or hyper- secretions of glandular 
products, are necessary for establishing the emotional disorder. The 
evidence on this point can be obtained from the work of Maranon (562) 
and Landis and Hunt (563). These investigators have demonstrated 
that the injection of epinephrine into human subjects was insufficient 
by itself to produce a true emotional experience. 

There is one other aspect of feeling and emotion that should be consid- 
ered at this point. Since the analysts have placed such great emphasis 
on unpleasant feelings and emotions as motivating factors in neurotic 
patients, the available data related to this notion should be presented. 
Many educational psychologists have also formulated their theories 
of learning in terms of the relative satisfaction or pleasantness of the 
organism's reaction. Here are two divergent views advanced to explain 
behavior and habit formation. Which is the more probably correct or is 
neither correct? The oblivescence of the disagreeable is a well known 
dictum. Yet it has been the source of much controversy. In some 
of the studies on the recall of pleasant and unpleasant events or hap- 
penings there has been a tendency for pleasant events to be remembered 
more often than unpleasant events (Gordon (564, 565), Cason (566)). 
This statement appears to support the analysts' contention that dis- 
agreeable feelings or emotions are relegated to the unconscious and 
cannot be remembered. Experiments, however, by other investigators, 
Henderson (567), Tait (568) show that the usual ratio of pleasant 
feelings to unpleasant feelings is approximately two to one; hence in 
normal recall and memory the expectancy of recall would be of the 
same order. Lanier (569) found that there was very little difference 
in memory value for words having pleasant, unpleasant, indifferent or 
mixed affective values. The words in the various categories of affective 


values do not produce a marked difference in the psychogalvanic response, 
except for those in the mixed category. Sharp's (570) and Flanagan's 
(571) studies present a somewhat novel approach to the problem of 
repression. A list of paired associates containing syllables that were 
meaningless when presented apart from each other but suggested 
profane or sexual meanings (dah-mit) when presented together was 
prepared. Then there was prepared a similar list of paired syllables 
(res-ler) that aroused only neutral associations. There was better 
recall for the control lists than tor the experimental lists after twenty- 
four hours. On the whole, there seems to be little evidence for the 
notion that recall is seriously impaired by repression of the disagreeable. 
The clinical aspects of feeling and emotion will be considered in a later 
chapter and the relation of emotions to somatic changes will be presented 
in the chapter on Psychosomatic Disorders. 



The disorders subsumed under the term psychosomatic disorders have 
been recognized in the field of psychiatry for many years. It is only 
within recent years that the term has become popular. It has been an 
accepted fact that emotions tend to distort behavior and may even pro- 
duce degenerative organic changes in various organs of the body. Many 
of these disorders have been mentioned already in the text and others 
will be discussed in later sections of the book. In order that the student 
may obtain an overall picture, we shall present a resume of the topics 
covered in the conventional texts on psychosomatic medicine, e.g., 
Alexander and French, Studies in Psychosomatic Medicine (572), Dun- 
bar, Synopsis of Psychosomatic Diagnosis and Treatment (573), and 
Weiss and English, Psychosomatic Medicine (574). The topics covered 
vary somewhat with these authors. On the whole the psychosomatic 
problems most representative are those associated with autonomic and 
somatic nervous system functioning. Disorders of the alimentary tract, 
nervosa anorexia, peptic ulcers, mucosa colitis and fecal elimination; 
disorders of respiration, including bronchial asthma; disorders of secre- 
tion and elimination of urine; disorders of cardio- vascular function in- 
cluding hypertension; disorders of sexual and reproductive functions; 
disorders of glandular secretion; disorders involving skin reactions; dis- 
orders associated with arthritis and rheumatism; and many striated 
muscle reactions such as tics and compulsions, are the main topics 
covered. Work on frustration indicated clearly that emotional tension 
is built up when the frustration is persistent. It is not surprising then 
that those functions under autonomic control are greatly affected since 
even a show of emotion and usually striped muscle response must be 
inhibited and often suppressed. Neither of these reactions is completely 
obliterated and there results a continuous tension effect which may 
produce such things as headache from the tension generated in the 
muscles of the neck and scalp, or headache from vascular spasms of the 
arterioles of the brain which interfere with circulation. Frustration 
may produce a stomach ache from continued contraction of the stomach 
muscles or from flatulence arising through over-secretion or under-secrQ- 



tion of the duct glands supplying the juices neccessary for proper diges- 
tion. Many of the explanations that have been offered for psycho- 
somatic disorders are similar to those advanced for explaining the 
functional disorders of psychoneurotics. Grinker and Spiegel (575) 
maintain that there is a distinct difference in the purpose of the symp- 
toms, stating that psychoneurotics utilize their symptoms as a means of 
resolving conflicts while individuals with psychosomatic ailments cannot 
or do not utilize their disorders in the same manner. They maintain 
that the former seem relatively free from distress about their symptoms 
while the latter may manifest great distress over their symptoms. There 
seems to be, however, no real need for the distinction as far as etiology 
and therapy are concerned. Alexander (576) cautions against the as- 
sumption that conversion symptoms in the vegetative system follow 
rules similar to those which apply for the voluntary and sensory systems. 
In the vegetative system there is likely to be an intermediate chain of 
physiological processes. Since we are dealing with functions under the 
control of the autonomic and somatic nervous systems, a brief statement 
of the role of the hypothalamus should be presented. According to 
Grinker (577) the hypothalamus integrates all visceral and autonomic 
activity and balances the activity of the parasympathetic and ortho- 
sympathetic divisions. The parasympathetic acts as an inhibitor on 
activities, conserves resources, and builds up tensions. The ortho- 
sympathetic system enhances the functions of sensorimotor equipment 
and serves to discharge internal tensions. The hypothalamus "effects a 
rise in blood pressure, control of the arterioles, dilatation of the pupils, 
elevation of hairs, increase in blood sugar and adrenalin, increase in 
heart rate, contraction of bladder, uterus and gastro-intestinal tract, 
secretion of tears and saliva, regulation of body temperature and sleep 
regulation." The hypothalamus not only influences cortical activity 
but is influenced in turn by cortical activity. There is abundant evi- 
dence which points to the importance of the hypothalamus in syndromes 
encountered in mental disorder. It is not surprising that in psycho- 
somatic disorders the role of the psychogenic factors is considered 
important when the intimate relationship between the soma and the 
cortex is so clearly established. 

The psychoanalyst's approach to the problem of why a particular 
organic manifestation results from psychic conflict is somewhat vague. 
Some analysts have followed the general Freudian principle of the 
death wish or self-destruction instinct. The manifestation is only par- 
tial, however, and the affected organ is symbolic of the repressed idea. 


Organ neurosis is the abnormal use or innervation of an organ, which 
occurs because of a repressed tendency. Some theorists rely upon 
regressive trends and infantile modes of expression of emotions to explain 
the selective process. They hold that the various autonomic functions 
in relation to emotional development have gone through a particular 
course of evolution and the regressive level of the individual accounts 
for the involvement of a particular type of functional disturbance. 
Saul (578) states that some organic symptoms such as trembling and 
blushing are the direct result of emotional expression, while other symp- 
toms may be indirect. Symptomatology may occur because some 
response (not directly emotional) was involved in the emotion, i.e., 
soreness of the arms may be due to tensions set up during the process 
of dreaming about a conflict situation. Peptic ulcers may be caused by 
restricted circulation in the stomach coats, although the stomach and its 
activities are not directly involved in the conflict. Alexander (579) 
believes that it would be a mistake to interpret psychologically a duo- 
denal ulcer which arises from changes in motor or secretory functions 
due to emotions. The ulcer is the end result and has no psychological 
significance; only the change in motor activity or secretion is the direct 
result of emotions. 


Anorexia nervosa may manifest itself in the lack of desire for food or 
the inability to retain digested food. If continued for a long period of 
time, emaciation and inanition ensue. These symptoms will be accom- 
panied by changes in skin tissues, poor circulation and even temperature 
decreases. We have discussed in a previous chapter some ways in 
which this disorder may arise. Psychoanalysts hold that parental re- 
jection may be responsible. The child in particular gains attention by 
refusing to eat. Hunger in the child was associated with pleasure and 
sexual fantasies. In the adult, the denial of food is the denial of un- 
conscious sexual longings. Bulimia (particularly in the grief laden 
situation) which may be considered a somewhat similar disorder is 
presumed to arise in the psychoanalyst's opinion over a conflict situation 
in which the individual unconsciously wishes to eat the dead person 
(incorporate or identify with), and the rejection of food which represents 
the rejection of the idea. Vomiting which may accompany anorexia 
nervosa may be resistance to pregnancy wishes and incorporation or 
identification fantasies. 

Duodenal ulcers or peptic ulcers are associated, by some psycho- 


analysts, with ambition, excessive drive and a tendency to overcome 
obstacles at any cost. This aggressive behavior results from a feeling 
of inferiority and a resultant overcompensation to avoid unconscious 
passive receptive feminine tendencies. Other psychoanalysts stress the 
relationship between stomach functions and the care, support, depend- 
ence and love heaped upon the child by the mother in early stages of 
life. To escape this dependence, the adult becomes assertive and 
aggressive. In the scheme of Adler, the drive in these cases is the at- 
tempt to avoid dependence and to obtain superiority by achieving 
independence. It is stated that in those races or classes in which ambi- 
tion is lacking, ulcers are rarely encountered. Alexander (580) holds 
that the infantile wish to be loved, to be taken care of and to be de- 
pendent upon is rejected by the adult ego. Since these wishes cannot 
be obtained in normal life situations there is a regression to the wish 
to be fed, which activates and mobilizes continuously the stomach 
activities. We have thus a chronic innervation of the stomach. This 
chronic irritation and secretion results in the distress and ultimate 

Mucous colitis or spastic colitis patients often exhibit alternate periods 
of constipation and diarrhea. Saul (581) states: "Psychoanalytic studies 
of diarrhea and colitis cases show that the symptoms are stimulated 
chiefly by impulses to make restitution to others for grasping, demand- 
ing, receptive attitudes toward them, and also by impulses of hostility, 
depreciation, and soiling. The peptic ulcer patient usually compensates 
for his wish to be passive and dependent by real work, activity, exertion, 
accomplishment, and independence often exaggerated in order to deny 
the opposite. But the diarrhea patient only makes the gestures. The 
schema in these cases is that these urges are not acted out in life, but 
stimulate the autonomic nervous system, causing increased peristaltic 
activity of the bowels instead. This becomes a substitute activity a 
symbolic substitute for genuine accomplishment and giving." 

Alexander (582) follows somewhat the same line of interpretation. 
He postulates three major types in gastro-intestinal disorders: (a) gastric 
type (b) diarrhea type, and (c) constipation type. The first of these 
groups has intense receptive and acquisitive wishes against which the 
individual rebels because of feelings of guilt. The expression then takes 
the form of refusing to take or receive. The dynamics for group (b) 
proceed along these lines: The individual has a right to receive or take 
since he always gives. He has no need to feel guilty since he gives in 
return for what he gets. The dynamics for individuals in group (c) are 


stated in this manner: I do not have to give because I neither take nor 
receive. . 

Ruesch et al (583) present data that are difficult to interpret in a 
psychoanalytic vein. They quote various sources to show that war 
experiences tend to increase the rate of incidence in ulcers and that the 
sex ratio has shifted over the course of years from a higher incidence in 
females to a higher incidence in males. The first of these factors could 
still be incorporated into the psychoanalytic scheme but the latter is 
difficult to tie in with the theories. At least, the asumptions would 
have to be made: (a) that the mother principle and loss of approval have 
in some manner changed in the two sexes, and (b) the amount of jealously 
and aggression have been at the same time modified. Similarly the 
experimental production of ulcers in animals by the injection of physo- 
stigmine and pilocarpine do not tend to favor the psychoanalytic 
theories. Ruesch, in the study referred to above, found that the 
sociological factors in the life of an ulcer patient do not differ greatly from 
those of the population at large. The ulcer patients respond on the 
Minnesota Multiphasic Scale in a manner similar to hysterical and 
hypochondriacal patients. Ruesch et al imply that there is a capacity 
for disassociation of both organic and psychological functions. They 
also indicate that the ego organization is simple and primitive-like. 
This point seems to be at variance with writers who claim primitives 
and those from low social structures tend to have infrequent ulcers. 

The personality characteristics of the ulcer patients are described as 
dependence, psychological obtuseness, and lack of adaptability in social 
techniques. This description is borne out by the interpretation of 
the Rorschach responses. Seward, Fest and Morrison (584) studied 21 
male spastic colitis cases. These were relatively homogeneous as to age, 
socio-economic level and education and were diagnosed as of psychogenic 
origin. Personality profiles were obtained from the Rorschach, TAT, 
Rosenzweig Picture-Frustration test, and personal interview. They 

"The findings of the present study suggest a unique personality pattern for the spastic 
colitis subjects in this series. We have noted the absence of specific psychopathology. 
The schizoid features suggested by emotional evasiveness and difficulty in relating to 
people are counteracted by the strong trend toward social conformity. Moreover, neither 
neurotic anxiety nor ego defenses against it were found in our data. The interpretation 
that best fits our present findings is that the spastic colitis patient represents a form of 
character defect, which is especially indicated by his weak and inadequately defended 
ego, coupled with an inability to tolerate tension. Unlike the antisocial psychopath, 
however, the colitis patient is eager for social approval and is strongly motivated to con- 


form. Emotional situations evoking either dependency or hostility are felt as threatening 
by him. Since he lacks adequate social techniques for handling them adultly, he seeks to 
evade them. Instead of 'acting out' the surplus tension at the expense of others he 'acts 
it in' at the expense of his somatic health." 


Respiratory disorders, including asthma, have been partially discussed 
in an earlier chapter but we should like to present briefly here the point 
of view held by many of the psychosomaticists. Most of the theorists 
agree that the general picture of the asthmatic patient is one in which a 
dependent type manifests a strong emotional attachment to the mother. 
This dependency in dreams and fantasies takes on the form of need for 
security and protection, as is manifested by dreams in which it is 
claimed that intra-uterine fluids play a dominant role. These patients 
differ in their dependency on the mother from the ulcer cases, whose 
dependency takes on the role of need for food and nourishment. Any 
attack that would disrupt this dependency brings about a spasm. If 
the individual has sexual temptation, aggression, or any impulse that 
would displease the mother or mother figure, the asthmatic attack 
serves as a defense against carrying it out, thus the dependency situation 
is maintained. 


The impetus to the psychosomatic study of cardiovascular disorders 
arises largely from the report of Dunbar (585). After a survey of 1300 
patients, the conclusion was reached that patients who were hospitalized 
with different syndromes exhibited a definite personality picture. The 
7 syndromes included in the study were: fractures, hypertensive cardio- 
vascular disease, coronary occlusion, anginal syndrome, rheumatic heart 
disease, cardiac arrhythmias, and diabetes. Methods of evaluating 
personality consisted mainly of analyses of medical, social and psychi- 
atric histories. Her conclusions as to the personality make-up of each 
of these groups is representative of the point of view generally held by 
the psychoanalysts. Hypertensives show intense chronic, hostile im- 
pulses which seem to stem from a rebellion against attachment to the 
mother. These patients exhibit external friendliness and self control, 
but beneath this lie a strong aggression and hostility. Dunbar found 
that brutality on the part of one parent was often reported in the 
history of these patients. There seemed to be a strong attachment for 
the mother with intense fear of the father. Patients with coronary 
disease and pseudo angina, according to Dunbar, manifest a prominent 
sense of guilt and tendency to self punishment. Part of the self punish- 


ment takes the form of accident proneness. Alexander (586), in an 
analysis of patients with palpitation and extrasystoles, came to the 
conclusion that there was essentially a strong competitive attitude 
toward parents of the same sex. These parents represent an overwhelm- 
ing adversary with whom the patients have been in competition un- 
consciously. The struggle is a losing one because the parent is also a 
loved one whose love must not be lost. Since palpitation is a manifesta- 
tion of fear and danger, any situation which necessitates action but in 
which action must be inhibited produces the heart irregularity. 

There are relatively few objective personality studies on this type of 
patient, hence we are not able to verify the observations which have 
been made. Storment (587) has attempted to verify the personality 
pattern of patients with certain types of cardiac disorders. She em- 
ployed the Guilford and Guilford-Martin Personality Inventories that 
presumably tap a number of the personality factors observed by Dunbar. 
These were administered to hospitalized patients and the scores obtained 
compared with the postulation of Dunbar. Storment's groups consisted 
of hypertensive, rheumatic heart disease, coronary occlusion, arterio- 
sclerotic, and control cases. She concluded that while her study did 
not necessarily disprove some of Dunbar's contentions, the results do 
throw considerable doubt on the personalization of disease entities. 
This conclusion was arrived at because of inability to separate the various 
groups from each other and from the control groups. 

All of the observations on cardiovascular disorders are extremely 
interesting and may be valuable. However, until an objective study is 
made, in which the personality patterns are clearly determined before 
the disease entities are ascertained, too much significance cannot be 
attached to the studies. 


There is relatively little data of a psychosomatic nature available on 
skin disorders. However, the theorists all refer to a strong voyeuristic 
and exhibitionistic trend in the dream content of these patients. Skin 
lesions seem to be self induced upon occasion because of strong sadistic 
tendencies toward the opposite sex and self mutilation represents an 
atonement for this guilt feeling. Conflict over exhibiting one's body 
and guilt and shame associated with such exhibitionism may give rise 
to dermatoses. Sweating, blushing and blanching are normal activities 
associated with emotions. In addition, endocrine disturbances are re- 
lated to skin conditions. Changes in skin tissue are encountered in 
hypothyroidism and changes in sex gland output. 



Certain of the psychological relationships are discussed in the chapter 
on cutaneous disorders. Johnson, Shapiro and Alexander (588) have 
presented a summary of the literature in this field and have worked out 
the dynamics they believe to be functioning. Their observations were 
made on 33 cases of rheumatoid arthritis, most of whom were females. 
The overt personality features described by them are as follows: in their 
early life the female patients were inclined to outdoor activities and 
sports, being in addition somewhat tomboyish. In later life there was 
a very strong tendency to control their emotional expression and the 
need to be of service to others. They are dependent upon others but 
mask their dependence by service to others. There is evidence of a re- 
jection of their feminine role and they assume masculine roles and can- 
not yield satisfactorily in sexual matters. They state more specifically 
that all the female cases are classic examples of masculine protest, i.e., 
rejection of the feminine role. They tend to identify themselves with 
the male role, assuming many of the normal activities of the male. 
The actual arthritic effects may be produced by emotional states which 
bring about changes in temperature, circulation and endocrine functions. 

The following topics have been dealt with adequately in other parts of 
the text and will not be discussed in this chapter: 

(a) Disorders of secretion and elimination of urine 

(b) Disorders of sexual and reproductive functions 

(c) Disorders of glandular secretion 

(d) Disorders of striped muscle reactions 

While the authors subscribe to the fact that psychogenic factors pro- 
duce many disturbances of functions under control of the autonomic and 
sympathetic nervous systems, they believe that many of the criticisms 
leveled against psychoanalysis must be kept in mind when appraising 
the dynamics of psychosomatic disorders. This is especially true since 
many of the postulated dynamics have been devised almost entirely 
from psychoanalytic theories. In addition, many experiments with 
animals show that the psychosomatic changes encountered in humans 
can be induced and cured by procedures in which emotional factors play 
little or no part. We must again caution against accepting too readily 
psychosomatic explanations for many of the disorders discussed. Favor- 
able therapeutic results have been and still are being accomplished by 
workers in internal medicine and in endocrinology. 



The three phenomena, sleep, dreams and hypnosis, cannot be viewed 
as abnormal in accordance with the definitions set forth at the beginning 
of the book. If perceiving, thinking and feeling are the usual charac- 
teristics of the organism, then sleep, dreams and hypnosis represent 
certain modifications of these processes. Three different stages of dis- 
integration may be involved. In dreamless sleep, the maximal loss of 
these functions exists; dreaming may represent an intermediate stage 
in which not only the reflexes are active but also sensory stimulation 
plays a prominent part (this stage corresponds closely to some conditions 
of intoxication from alcohol and drugs in which the inhibitory influences 
of certain cortical centers are lost) ; hypnosis may tentatively be classed 
as the condition most closely approximating normal activity. The 
reflexes are intact; selective stimulation is effective; inhibition to a cer- 
tain extent is operative; and volitional control may or may not be lost. 
Aside from the fact that sleep, dreams and hypnosis are marked by un- 
usual conditions of perceiving, thinking, and feeling, sleep shows varia- 
tions of its own, and these variations must be explained as abnormal 


The classical theories of sleep have been critically evaluated by 
Haberman (589), Coriat (590) and Davison and Demuth (591). The 
latter authors give an excellent survey of the recent neurological and 
biochemical literature relating to disorders of the sleep mechanism. 
These theories fall into several categories which are: (a) chemical 
theories, (b) physiological theories, (c) neurological and histological 
theories, (d) psychological theories and (e) biological theories. The 
first three of these theories have some common features. The main 
differentiation lies in the emphasis placed upon the exact nature of the 
factor producing sleep. 


The chemical theory supposes that toxins created by muscular and 
neural activity accumulate during wakefulness and upon reaching a 



certain level produce sleep. In order to account for the desire for sleep 
following physical and mental activity, two different points of view have 
been taken. One theory assumes that the fatigue following muscular 
activity sets free some toxic agent such as "kenotoxin" or lactic acid in 
the blood stream which finally reaches the nerve cells in the brain and 
that mental fatigue is the result of auto-intoxication of the nerve cells. 
The other theory assumes that the drowsiness following muscular ac- 
tivity is due to the exhaustion of the nerve innervating the muscle and 
that mental fatigue is due to the exhaustion of the muscles which func- 
tion in imagining and thinking. 


The physiological theories have been founded upon physiological 
changes following activity or loss of sleep. Perhaps the physiological 
theories which are discussed here are not theories at all but only a de- 
scription of some physiological changes that occur during sleep. Almost 
every physiological function has at some time been used as a basis for the 
construction of a theory. It would be outside the scope of this text to 
examine them all and only the more general ones will be mentioned. 
The circulatory theory had its origin in the observation that humans 
assumed a prone position when going to sleep. The numerous species 
of animals that do not assume this position were overlooked. Follow- 
ing the observation just mentioned, delicate balancing boards were 
constructed to show that the blood retreated from the head toward the 
stomach and extremities. The outcome of these experiments was, of 
course, nil. The notion of a change in circulation persisted since many 
people noticed the tendency to become drowsy after a heavy meal 
Fainting spells following hemorrhages, the sleepiness of anemia patients 
and of the obese furnished contributory data to circulatory changes. 
The proneness of the body which the observers believed favored an 
increased blood supply to the brain did not conform to the other evi- 
dence. As a result, two diametrically opposed theories were proposed. 
The first of these is referred to as the "anemia theory." The general 
assumption is that the lessened flow of blood to the brain results in a 
temporary undernourishment of the nervous tissue. Sleep, then, is not 
a period of recovery or anabolic activity, but one of breakdown or cata- 
bolic activity. 


Some theories to which the name biological has been attached should 
be designated as mystical. Theories of this type have been advanced 
by Claparede, Sidis and Coriat. Claparede (592) suggests that sleep 


is instinctive and that we sleep to prevent fatigue rather than as a result 
of fatigue. It has become habitual or acquired since only those organ- 
isms that conserve their energy by sleeping or by becoming immobile 
can manifest the necessary increased energy required to protect them- 
selves from their enemies. These instinctive sleep responses can be 
conditioned in the same way that other instinctive responses are con- 
ditioned. Thus, for the stimuli which originally produced sleep are 
substituted the conventional postural changes, closing of the eyes and 
all the other physiological concomitants. 

The theory of Sidis (593) is similar to that advanced by Claparede. 
His assumptions are partly neurological, partly psychological and partly 
mystical. The neurological aspect of his theory involves the change in 
threshold level of the cell energy. The psychological assumption is 
that cells become de-energized by repeated monotonous stimulation so 
that afferent impulses are not effective in stimulating the organism. 
These stimuli are replaced by other modal stimuli until the gamut is 
completed. When all possible avenues are de-energized, the organism 
falls asleep. The mystical part of Sidis' theory is his assumption that 
sleep is instinctively developed out of the hypnoidal state (a condition 
intermediate between sleep and hypnosis) which in the evolutionary 
scheme is far older than either. Pavlov's (594) inhibition theory of 
sleep is not unlike that advanced by Sidis. Inhibition is produced by 
monotonous stimulation or absence of stimulation which gradually 
results in inhibition of the whole cortex. 


The notion of reduction of peripheral stimulation embodied in the 
theories of Sidis and Coriat resembles very closely the theories of 
Mauthner and Tromner advanced several years earlier. Sleep, according 
to Mauthner (595) and Tromner, (596) is attained by blocking off all the 
cortex from incoming peripheral stimuli. Haberman (597) has presented 
pertinent evidence for and against cortical blocking. A quantitative, 
if not qualitative, reduction is found in the conditions which favor sleep. 
Darkness, quiet, and relaxation reduce three modes of peripheral stim- 
ulation. Monotonous stimulation such as a flashing light, roll of the 
waves, the rhythmical sounds of car wheels tend to limit the variety of 
stimuli since they become foci of attention. 


A histological theory of sleep is based upon the supposed amoeboid- 
like movements of the dendrites of the nerve cells. These dendrites are 


the means by which nerve currents are transmitted from one part of the 
body to the other. When anything causes the dendrites to retract or 
produces a change in resistance, sleep ensues. The dendrites unfortu- 
nately may or may not have this ability; and if the ability is postulated, 
either a voluntaristic role must be assigned them or the change is brought 
about through constant usage. This latter view is simply a variation 
of the fatigue or metabolic theory. 


The theories which account for sleep do not throw any light on norms 
of sleep, i.e., the length of time required, the so-called "depth of sleep," 
and the actual amount of coordinated activity permissible that may still 
be described as sleep. Individual differences in sleep requirements are 
quite marked. Most textbooks state that the average individual re- 
quires about 8 or 9 hours sleep out of 24, taken at one time. The varia- 
tions from this schedule are pronounced in infants and elderly people. 
They do not sleep as long at a time but require frequent periods of sleep 
of shorter duration. The necessity of this is usually explained on a basis 
of fatiguability. Many adults do not feel any ill effects on as little as 
5 or 6 hours sleep while others feel drowsy and tired unless they take 
from 10 to 12 hours sleep per night. Habits play a dominant role in 
sleep needs and when once established are difficult to break. A safe 
guide as to the amount of sleep that should be taken can be established 
by taking that length of sleep that leaves one feeling rested and re- 
freshed in the morning. 

Most studies on the depth of sleep have been highly unsatisfactory. 
The data, with but few exceptions, have been obtained from few cases or 
the criteria under investigation have been considered to the exclusion of 
other pertinent criteria. Various methods have been employed. The 
psychological methods have centered in the strength of stimuli required 
to awaken a sleeper after a lapse of a period of time. Sound stimuli 
(employed by Michelson and Kohlschiitter) such as the noise made by 
dropping a steel ball from varying heights or the noise of a buzzer,, 
varying intensities of electric shock, tactile stimuli (employed by De 
Sanctis and Neyroz) applied by varying lengths of bristles, and activity 
measurements (employed by Johnson and Weigand, and Karger) have 
been tried. The method of measuring activity used by Johnson and 
Weigand consisted of mounting beds so that major movements and the 
time of their occurrence could be automatically recorded. There may 


be some question as to the validity of movements as a criterion of the 
depth of sleep. This objection is of course pertinent since some move- 
ments unquestionably take place without awakening; however, there is 
probably a direct relationship between the number of movements and 
the state of integration. On a basis of experiments similar to those 
described, conflicting results have been found. The first two methods 
yield results which according to the experimenter's contentions, showed 
that the greatest depth of sleep occurred in the second hour with gradual 
diminution until awakening. Not only have the methods used been 
subject to criticism but also the interpretation of the data has been 
questioned. Johnson and certain of the other investigators have felt 
that the depth of sleep is a highly irregular process. Some individuals 
tend to rest more in the early part of the night; others in the latter part 
of the night. This varies for individuals as well as from night to night 
for the same individual. 

Some of the physiological indices of sleep have already been dis- 
cussed. There are two others that should be mentioned since they may 
have some bearing on the qualitative aspect of sleep. Richter (598) 
has noted marked differences in temporal variation of skin resistance of 
subjects during sleep. Skin resistance during sleep was found to in- 
crease maximally in a ratio of 16:1, when the electrodes were applied 
to the skin of the hands. Such large changes were not found when the 
electrodes were applied to other parts of the body not abounding in 
sweat glands. He attributes this change in resistance to decreased 
activity of the sweat glands. Work of a similar nature by another 
investigator has not substantiated Richter's results although the 
methods used were not identical. The observations of Karger (599) 
tend to disprove Richter's contention. Karger found that the rate of 
perspiration in children increased greatly about 2 hours after sleep. 
This is usually thought to be the period of deepest sleep. Miles (600) 
also disagrees with Richter's findings. He states as a result of observa- 
tions on himself, on loss in body weight during sleep that "In the longer 
normal sleep the latter portion approaches more to the waking condition 
and has a higher rate of loss." Thus, if the loss is greater as one ap- 
proaches a waking state, the skin resistance should be lower since skin 
resistance is dependent upon rate of perspiration. Liberson (601) found 
that the EEC during sleep changes with the depth of sleep, but there is 
a wide variety of "sleep patterns." These seem to be individual in 
nature. He reports further that there are some characteristic patterns 
with mental disorder syndromes. 



Abnormalities of sleep follow a graded scale from almost complete 
insomnia to prolonged sleep or coma. Insomnia is the inability to 
sleep in spite of the need for and intense desire of sleep. Clinical studies 
have been made of insomnia produced by various physiological con- 
ditions. These have been elaborated under the theories of sleep, but we 
may mention again the role of stimulants such as caffeine and strych- 
nine, unusual fatigue, pain, and brain tumors in hindering sleep. Un- 
usual stimuli arising as a result of a change in the pattern surrounding 
sleep conditions and emotional disturbances tend to produce similar 
results. The city dweller may be unable to sleep in the country and 
vice versa. Absence of familiar stimuli certainly is important. One 
who is accustomed to sleeping in a particular position may be restless 
and unable to sleep if unable to assume that position. A person who is 
accustomed to sleeping with someone may experience difficulty in 
sleeping alone. The habit of reading one's self asleep may prevent sleep 
when the habit cannot be indulged. The principle of absence of famil- 
iar stimuli furnishes the basis of the trouble in the transition period 
when one tries to abolish drugs and sleep without their aid. Taking a 
sedative becomes part of the pattern necessary for sleeping, and any 
change in the pattern breaks up the series of adjustments essential for 
sleep. Intensive analysis of several cases of insomnia by Rothenberg 
(602) led him to the conclusion that the individuals had strong death 
wishes against some one over a period of time. The insomnia is pre- 
cipitated when actual or imminent death in the environment exists. 
This latter factor tends to reactivate older emotional patterns. Knott 
et al (603), in studying manic depressives, found that the electroen- 
cephalograms during sleep varied from those obtained from normal 

Whatever the cause of insomnia, we must discount the statements 
as to the amount of sleep lost by insomnia patients. Their reports are 
exaggerated since unfilled time is usually overestimated under normal 

It cannot be denied that prolonged insomnia is followed by grave 
physiological and psychological consequences. Studies have been made 
on both humans and animals under controlled conditions, so that a 
fairly accurate account can be given of enforced deprivation of sleep. 
De Manaceme (604) found that young puppies could survive loss of 
sleep for less than a week; 2 died in 92 and 143 hours. These animals 
were artificially fed and heated, thus death could not be assigned to 


starvation. Examination showed fatty degeneration in ganglion cells; 
capillary hemorrhages and an increased number of leucocytes. Crile's 
(605) report on the effects of 72 hours of wakefulness indicates similar 
effects. Cellular changes occurred in the central nervous system which 
were quite similar to changes produced by starvation, muscular ex- 
haustion, and narcosis. 

Insomnia, for a period from 40 to 115 hours produced, according to 
Kleitmann (606), in healthy human subjects no apparent variation from 
the normal in the following factors: mean temperature, rate of oxygen 
consumption, blood sugar, number of leucocytes and of red blood cells, 
alkaline reserve, and body weight. Similar results were obtained by 
Moss (607) and his associates from 60 hours of sleep deprivation. These 
authors maintain that there was an increase in leucocytes and a decrease 
in red cells and hemoglobin. Katz and Landis (608) found that a 10 
day vigil of one subject produced no evidence of any real change in 
physical or physiologic function which could be attributed to the period 
of sleeplessness. Metabolic rate, blood pressure, pulse rate, blood count, 
and urine analysis were unaltered by the vigil. The psychological 
effects of insomnia have been investigated by Gilbert and Patrick, 
Robinson and Hermann, Robinson and Robinson, Laslett, Kleitmann, 
Smith and Moss and his associates. The details of these experiments 
will not be given. In general, it may be said that deprivation of sleep 
for periods ranging from several hours up to 115 hours produced no 
significant effect on accuracy in aiming, rate of tapping, gripping, reac- 
tion time, association time, memory, learning and relearning, mental 
arithmetic, scores on "intelligence tests," threshold for auditory sensitivity 
and electrical stimulation, extent of the peripheral field of vision and 
the knee-jerk. Ataxia was increased and the pupillary reflex change 
was decreased. It is unsafe to conclude from these studies that loss 
of sleep causes no inimical effects, since Katz and Landis have dis- 
covered such effects from a more prolonged vigil. Many of the subjects 
of the earlier experiments showed definite symptoms of irritability, 
confusion, headache, nervousness, emotional disturbances and a wide 
variety of signs that could not be misinterpreted. The status of the 
matter is that the tasks set were inadequate for bringing out the induced 
changes. This is in general agreement with the findings on alcohol 
consumption, oxygen deprivation and carbon monoxide poisoning. The 
organism seems to be capable of temporarily compensating for such 
disturbances. Clark and others (609) found a definite decline in per- 
formance on complex psychological tasks after 50 hours of sleep dep- 


rivation. Licklider and Bunch (610) showed changes in the behavior 
and growth of rats kept on schedules of enforced wakefulness from 12 to 
24 hours daily. Many of the animals died from fighting among them- 
selves, and the growth of some of the control animals was impaired. 

Selective sleep is one of the topics about which relatively little is 
known. Almost every one is familiar with an individual who says that 
he can awaken at any time. The well-known phenomena of the mother 
awakening to the slightest movement of her offspring and the awakening 
of the nurse anticipating the wants of a patient belong in the same class. 
Much speculation concerning the reliability of such performances has 
been written, but the authors are inclined to be skeptical of most of it. 
Apparently integration is so arranged that the threshold for a particular 
type of stimulation is lowered. This theory of selective arrangement of 
thresholds is difficult to explain on a basis of stimulus-response psy- 
chology. It almost demands a mystical explanation in terms of the 
unconscious mind or the assumption of mental processes independent of 
neurological processes. 

Two other abnormalities intermediate between waking and sleeping 
are pavor nocturnus (nightmare) and somnambulism (sleep walking). 
Pai (611) studied 117 male neurotics alleged to walk in their sleep. He 
mentioned that the clinical condition was one of incomplete sleep with 
varying degrees of consciousness. These sleep walkers contrast with 
post-epileptic patients who have automatisms. The latter, Pai be- 
lieves, are entirely devoid of consciousness. The explanations of these 
disorders are quite similar to those advanced for sleep itself and other 
dissociated phenomena which will be discussed later. 


Undue or compulsive desires for sleep are called narcolepsy. Numer- 
ous conditions of this kind occur in the population at large and were of 
sufficient frequency in the armed forces to be given careful attention. 
Fabing (612) attributes the following etiological classification to Wilson: 
Narcolepsy may be produced by (i) trauma, (2) toxic-infectious states 
such as encephalitis, (3) epilepsy, (4) endocrine disturbance, (5) psycho- 
pathological disturbances, (6) local lesions (vascular and tumor), and 
(7) cryptogenic (obscure) conditions. 

In order that we may understand the significance of these etiological 
factors some of the neurological conditions which operate in sleep must 
be discussed. Present evidence indicates that the hypothalamus is largely 
responsible for the regulation of sleep. This in turn is influenced by 


fibers originating in the cerebral cortex, especially the hippocampal, 
angular, frontal, premotor, and temporal convolutions. The hypothala- 
mus is further influenced by connections with the thalamus, the striopal- 
lidum, and the hypophysis. The importance of the neurological tracts 
specified has been demonstrated in a number of ways. Experimental 
lesions on animals, electrical stimulation of various brain areas, injections 
of various pharmacological substances and clinical case material have all 
contributed to the picture. Ranson (613) produced experimental lesions 
in the hypothalamus area in monkeys and concluded that this area is the 
integration center for emotions as well as a waking center. When its func- 
tion is disrupted, somnolence occurs. Harrison (614) also tound that som- 
nolence resulted from bilateral lesions in the hypothalamic area. White 
(615) produced a tendency toward drowsiness in man by mechanical and 
electrical stimulation of the hypothalamus. Hess (616) claims to have 
induced sleep by stimulation of the brain stem although Harrison, 
Magoun and Ranson (617) showed that the electrical stimulation was not 
the agent but rather lesions produced by the electrical current were the 

Sleep disturbances and sleep have been investigated by the injection 
of various drugs. Since sleep has been presumed to be due to the 
dominance of the parasympathetic nervous system, those drugs that 
have an affinity for this system have been utilized. Marinesco, Sager 
and Kriendler (618) have tried injections of choline on animals. Choline 
tended to produce a sleep-like condition. Henderson and Wilson (619) 
tried injecting acetylcholine into the hypothalmic regions of humans 
but were unsuccessful in producing sleep. Ergotamine has also been 
employed but without success. Injections of calcium and other chemi- 
cal substances produce sleep-like conditions (Brunelli, 620). However, 
other experiments tend to show that the calcium blood level change is 
coincidental with sleep rather than preceeding it. 

The evidence from many sources tends to support the theory that the 
hypothalamus is one of the essential neurological mechanisms involved 
in sleep and its disorders. 

We should like to return to a consideration of the psychological theories 
of sleep for a few moments before continuing a discussion of narcolepsy. 
While sleep may be thought of as a general lessening of mental and 
biological activities of the organism, the theorists hold that this lessening 
or diminuition is a psychobiological protective* mechanism against ex- 
haustion. Sleep may be considered as a repression to avoid conflict 
with environmental problems, or stated in Freudian terminology, sleep 


is a reenacting of life in utero in which the ego escapes contact with the 
world and reality. Sufficient data have been given to show that unusual 
desire for sleep may arise from any one of the several causes listed 
earlier. More attention has been paid to insomnia but there are few 
studies on narcolepsy that contain a sufficient number of cases to warrant 
discussion. Solomon (621) found that negro recruits for the army had 
an incidence of this disorder which was 60 times that among white 
recruits. Nineteen of 10,000 negroes were found to be affected. Of the 
19 cases found, 16 appeared to be idiopathic and had their symptoms 
since childhood. Levin (622) reported 25 cases of soldiers discovered 
asleep on sentinel duty. He ascribed their delinquency to the following 
causes: rebellious psychopathic personality, insufficient rest, and idio- 
pathic disability. He interpreted the somnolence to a suppression of the 
impulse to escape a threatening situation or the somnolence may be due 
to excessive susceptibility of the cortex to widely irradiated inhibition 
(Pavlov's concept). Langworthy and Betz (623) studied 6 cases of 
idiopathic narcolepsy. They found no signs of disease of the central 
nervous system but ample indication of emotional disturbances. Stimu- 
lants afforded only temporary symptomatic relief but the patients did 
respond to psychotherapy. They also thought that the condition was 
an escape from emotional issues. 


Many people ask, how can insomnia be overcome ? There are certain 
practical suggestions that can be given in answer to this question. The 
environmental conditions should be made as favorable for sleep as 
possible. Exclusion of light, proper ventilation and maintenance of 
general noise conditions are advisable. These factors should be made 
to conform in so far as possible to those to which the individual is 
accustomed. Removal of physiological factors which produce dis- 
comfort, i.e., pain, flatulence, and muscular tension are advised. Sim- 
ilarly, emotional excitement and extreme mental activity should be 
avoided. The ability to overcome such inhibitors of sleep is abetted 
by the direction of the thought into a single channel. The old remedy of 
counting sheep or listening to the clock tick may help. In general, 
reestablish the pattern usually assumed when going to sleep. Changes 
in circulation produced by eating or drinking something warm, alcohol 
rubs, and tepid baths tend to be sleep-inducing since increase in blood 
in the extremities and stomach tends to decrease it in the brain. Avoid- 
ance of stimulants is a good rule to follow although the amount of 


caffeine taken in a cup or even two cups of coffee is usually insufficient 
to keep one awake unless the belief is strongly entrenched. Giddings 
(624), using motility as the index of sleep, found that 6 ounces of warm 
milk at bedtime produced quiet sleep in normal children and that 
beverage which contained .6 of a grain of caffeine produced no more 
restlessness than a similar quantity of orange juice. Baths, either 
warm or cold, did not produce constant effects. It would appear that 
the effects are individual in part and should be worked out to suit the 
case. If all of the aids mentioned are ineffective, recourse may be had 
to a variety of drugs. These are advised only under the guidance of a 
competent physician since some of them are habit-forming and since 
knowledge of their effects on the nervous system is limited. Some of 
them have been administered for periods of years without any apparent 
harmful results. If the use of drugs is accompanied by worry about 
their effects, the benefits will certainly be lessened. Another method, 
which should be applied only by an expert in the technique, is hypnosis. 
The writer favors this method, since no neurological breakdown can 
ensue. Post-hypnotic suggestions may be given at the same time, which 
will help the patient establish normal sleep habits. 


The reader of this book has in all probability been mystified at some 
time or other when he has attempted to explain why certain things or 
events have played a part in his dreams. No two psychologists would 
give identically the same answer to his questions and if psychoanalysts 
were consulted, still wider variations of explanation would be offered. 
Since psychoanalysis has been in vogue, few psychological studies of 
dreams have been made. In this section of the book we will try to set 
forth the pertinent facts about dreams and ignore the pseudo-psycho- 
logical interpretations of the analysts. These have been discussed 
partly in an earlier chapter. 

The basis of our discussion will be the reaction theory which hypothe- 
sizes the four following points: 

(1) Stimulation of receptors which arouses afferent current; this 
afferent current reaches the brain stem or spinal cord and is finally 
shunted through the cerebrum or cerebellum which in turn results in 
efferent current to the muscles or glands. 

(2) In the central nervous system there are any number of possible 
synaptic connections so that any given afferent current may be shunted 
on to any given efferent route. 


(3) The central nervous system tends to unify or integrate all of the 
afferent impulses. Instead of having a number of independent reac- 
tions, the manifold afferent impulses tend to become fuctionally con- 
nected and result in a single discharge or orderly series of discharges. 

(4) Instead of an isolated stimulus producing a reaction of an isolated 
muscle group, the total mass of stimuli affect the action mechanism 
of the body generally, although a limited group of stimuli and a re- 
stricted group of muscular activities may predominate at any given 

With these assumptions Dunlap (625) says in writing of sleep and 
dreams that: 

we should expect to find, as the integration falls apart, that certain parts of the system 
might continue to function with fair efficiency, as small systems, just as we do find the 
"vegetative" functions and certain mechanized reaction processes going on: and we are 
not surprised that these should show occasional "spurts" of high activity. 

Sensory stimulation will not, in general, during sleep, produce its customary reactions, 
and hence not its customary consciousness. But detached effects are produced, and some- 
times, if the stimulation is sufficiently intense, integrative results somewhat resembling 
the normal will be momentarily produced. Moreover, random detached ideational 
processes must occur; for ideational process must inevitably be found to be a reaction 
process, just as is perceptual process. In short, on the basis established, without referring 
to experience at all, we could predict that dreams must be possible. It could be pre- 
dicted that these dreams would vary all the way from the lowest degree of vividness 
(degree of attention), and the lowest degree of inconsequentiality, to a vividness and 
connectedness resembling the most attentive and coherent waking thought processes 
and perceptions. In fact, odd as the statement may seem, if we had not this firm basis 
in sound theory, we would have real difficulty in establishing that dreams actually occur! 
For, it might be urged that all so-called dreams are really constructed in the first process 
of recalling them, since it is a demonstrable fact that a great deal ot what we report 
as having been dreamt is constructed in the recalling. But we have the evidence for 
the reality of dreams in these facts: first, that on our empirically derived theory, dreaming 
is obviously possible; second, that the physiological functioning of sleepers is affected in 
the way it should be if, in accordance with the theory, dreams occurred; and third, that 
it has been experimentally shown that stimuli applied to sleepers produces on their 
alleged dreams precisely the effects it should produce on real dreams. 

Dreams are unquestionably initiated by sensory stimulation, feelings, 
desires and general ideational processes concomitant with low degrees of 
integration. The role of oensory stimulation in the production of 
dreams has been most extensively studied by Horton (626, 627, 628). 
He explains all dreams on a basis of sensory impressions that are elabo- 
rated or misinterpreted by the attempt of the integrating system to 
organize these sensations into some orderly system. The ability to 
reduce them to a system is lacking because of the low function of the 


integrating tendency. Auditory sensations may be elaborated into 
battles, accidents or storms; cutaneous sensations may give rise to 
dreams such as wading in water or lying in the sun on a beach; proprio- 
ceptive and interoceptive stimuli may lead to dreams of being choked, 
fainting, flying or levitation dreams. An example or two of sensorially 
aroused dreams will help to clear up the matter, (i) One person who 
suffers from head noises due to an ear disorder has recurrent dreams of 
thunder and lightning, sometimes accompanied by windstorms and 
tornados. Invariably these dreams take place when atmospheric 
conditions increase the head noises. The sensations arising from the 
circulatory changes in the ear are interpreted as thunder, and the 
elaboration of the dream adds the lightning and wind. The processes 
of association are not unlike those in normal waking life since thunder 
is usually accompanied by lightning and sometimes by windstorms. 
(2) The following dream was related by a student who went to sleep 
with a mild toothache. He was engaged in a boxing bout with one of 
his college friends in which he received numerous blows on the jaw. 
After the bout was over his face was swollen and sore on one side. The 
pain sensations were thus interpreted in terms of blows on the jaw. 

The experimental investigations of Cubberly (629) in which he applied 
pieces of gummed paper about % of an inch square, or oily substances 
over an area of 3 inches in diameter to various parts of the body illustrates 
clearly the effects of these mild forms of stimulation upon dreams. 
In an analysis of 750 dreams the influence of these agents was marked. 
For example, when the tension is applied to the sole of the foot, dancing 
was foremost in one of the dreams; when the relaxing agent was applied 
to the right wrist on the palmar surface, one dreamed of fitting a tube 
into a pipe to control the overflow from a cistern. The use of the 
hands is indicative and Cubberly discusses a series of these dreams in 
terms of the position taken by the hands in performing various tasks 
dreamed about. 

Although stimulation of the special senses can be shown to be effective 
in causing dreams, this is insufficient reason to rule out many of the more 
complex methods of arousing reaction. Desires, feelings, and emotions, 
whether carried over into sleep or aroused during sleep have their effects 
when their respective mechanisms come into play. Aversion, fear, 
hope, worry are very efficient in dream production. Anticipation in 
conjunction with an emotional state is probably the most effective, 
although emotions without anticipatory elements are demonstrably 
effective. A pleasurable or painful experience unassociated with 


anticipation or wish may recur in a dream; or the emotion recurring, 
may arouse some other past experience, through association with the 
same emotion. The ideational factor connected with the emotion in 
the dream may be one previously associated with it and not the one of 
the moment; hence the first of these ideational factors and not the second 
is responsible for the occurrence of the emotion in the dream. Another 
quotation from Dunlap (630) presents the point of view which we hold 

In the low integration of sleep, a given perception, or a given idea, will not in genera' 
arouse in memory the associated idea which it would be most likely to arouse in waking 
life. The same laws apply in sleep as in waking, but the conditions of associative recall 
are always exceedingly complex, and any change in the condition must change the result. 

To assume that ideas are associated with each other, and with emotional factors, in 
simple one-to-one ways, is to miss entirely the facts of association. Undoubtedly, in 
cases where dreams are directed by stimulation of the external senses, as in the universal 
dream of nakedness, which in most cases is so clearly due to dermal chilliness, the direc- 
tion is in large part through the unpleasant emotion directly aroused by the chilliness. 
In such circumstances, the dreamer seldom if ever dreams of pleasant situations, although 
if the dream were really a "fulfillment" of a "repressed" sexual wish, as the Freudians 
ingeniously suppose, we should expect the fulfillment to be most frequently pleasant. 

The importance of the emotional factors in dreams is strongly emphasized by the 
universal dreams, such as that of being nude. The dream of flying: of moving through 
the air by merely "flapping" the arms, or by some other absurd means, is apparently 
due to respiratory feelings. The dream of falling, always colored by a strong emotional 
feeling, may perhaps be due (this is a tentative explanation), to spasmodic contraction 
of a certain group of genito-urinary muscles: a contraction which uniformly occurs in 
actual falling, or even in the sudden thought of falling, as when one comes unexpectedly 
on an open elevator shaft, or the perception of some one else falling. In any event, 
the emotion aroused is the important thing, and suggests the ideational factors of 
the dream. 

Many dreams aroused through emotional processes are reproductive 
in type; that is, in the dream the individual relives a particularly strong 
emotional experience. The dream of the hypnotic subject related 
earlier in this book was of that nature. There was a reproduction of an 
actual incident in the subject's life. Some dreams of collisions in 
automobiles and the recurrent dreams of soldiers, of shells exploding are 
produced by the activation of some mechanism which was involved in 
the original perceptual experiences. Other dreams are indirectly 
aroused in this manner through association processes. Wish fulfillment 
and aversion dreams may not be simple reproductions but more com- 
plicated in their arousal. The importance of emotional factors in such 
dreams has been stressed by Selling (631) in his study of juvenile delin- 
quents and convicts. About 80 to 96 per cent of the dreams of the 
juvenile delinquents was about their home life and about 72 per cent of 


the dreams of adult prisoners was a straightforward account of what 
they admitted they visualized during waking hours. 

There are some general facts that may be stated about dream content. 
The types of imagery that prevail in dreams are comparable to those 
that prevail in waking life. Visual and auditory imagery head the list. 
The content of children's dreams varies with the social condition of the 
home and as the child grows older fear begins to be manifested. The 
fact that fear is not manifested until late in life in dreams opposes 
Watson's notion of fear being one of the innate emotional responses. 
One characteristic of dreams which is somewhat difficult to explain is 
the fact that they are more often unpleasant than pleasant, especially 
in view of the findings that pleasant experiences occur much more 
frequently than unpleasant experiences. The speed of dreams and 
telescoping of time intervals have aroused considerable interest. For a 
long time the notion was held that the rate of dreaming was faster than 
the rate of waking associations and thinking. The fallacy of this con- 
tention has been pointed out by many writers. Accurate data are not 
available to determine just how long a dream lasts although Max's 
study of action potentials of deaf-mutes shows that their dreams occupy 
more than the conventional i or 2 seconds. 

Max (632) has developed an ingenious method for determining 
whether dreaming is taking place, the length of time it lasts, and the 
eftect of various forms of sensory stimulation on the response mecha- 
nism. By securing the action potentials during sleep and comparing 
the changes that occur throughout sleep, he is able to predict when the 
subject is dreaming, how long he dreams, and what part of the muscula- 
ture is involved. If the subject is awakened when the action potentials 
reach a certain level during sleep, it has been found that the subject 
was almost invariably dreaming. He has found also that the high 
action potential level lasts during the time that the subject dreams. 

Some people have gone to sleep and a few moments later have been 
awakened and have reported lengthy dreams; others have been awakened 
immediately after specific sensory stimulation and have reported dreams 
which have been initiated apparently by the stimulus. These dreams 
that require considerable time for their telling or even thinking through 
can be explained by the fact that a few detached dream ideas have been 
woven into a connected story by normal associative processes adequate 
for interpreting the fragments. This idea of waking elaboration gave 
impetus to the theory that dreams are manufactured after awakening. 
Successive relation of dreams indicates that the dream becomes better 


organized, and many details which were lacking in the first telling appear 
in later recountings. Moreover, stimuli which are incorporated into 
dreams in an inverted order, that is, a considerable part of the dream 
is put before the stimulus, appear too frequently to assume that they 
just fitted into a dream already in progress. For example, an elaborated 
dream of fighting may terminate with a loud crash. It is highly prob- 
able that the loud crash really initiated the dreams, but in the process of 
fabrication the dream preceded the stimulus. Telescoping of time is 
not infrequent in dreams just as it is carried out in novels. One dreams 
of skating across a lake and before he has reached the other side, spring 
has set in and the ice has melted. This type of association could be 
predicted on a basis of normal associations. A skillful writer may have 
his character in a story grow up from an infant to an adult within a few 
paragraphs. Simultaneity of dreams is due to the waking organization 
of a great many dream fragments into two or more unified parts. This 
procedure is the simplest and requires less additional material for mak- 
ing them connected narratives. 

In a general way, the problems and every day experiences, as well as 
the personality of the individual, are important in shaping dream life. 
Pierce (633) has compared the dreams of a writer, a lecturer, a farmer, 
a teacher, a scientist and individuals in other occupations and finds a 
marked similarity between the dream content and the factors pertaining 
to their daily environment and personality. This is not surprising in 
light of our knowledge of dream motivation and the processes of associa- 
tion both in the waking and dream life. It has also been shown that 
dreams of psychopathic patients conform to their general feeling tone 
as well as to their mediate and immediate experiences. Similarly, the 
dreams of drug addicts are probably influenced by the feelings aroused 
by the drugs themselves. 

Hall (634) has demonstrated rather clearly that dreams are initiated 
by present emotional conflicts. He asked students to record their 
dreams over a period of time and by obtaining a number of them in 
sequence he could reconstruct the conflict situation in a rather accurate 
manner. A complete series of dreams of one of the students is quoted 
from Hall's 1 study. 

Case B 

''Subject: Female, 19 years, college sophomore. 

Basic conflict: A desire to remain faithful to her husband, who is in the army overseas, 
vs. a wish for sexual gratification. 

1 Hall, C. S. Reprinted by permission from the Journal Abnormal and Social Psychol., 
1947, 42, pages 77-78. 

Spotlight dream Bi. Last night I dreamed that I was walking up the stairs in the 
administration building and some way or other my dress was flying up around my waist. 
I remember being terribly embarrassed as the stairs were crowded with students. As I 
remember, I was running for some sort of an office (that is, I was a candidate) and that 
was no way to win an office. 

Spotlight dream B2. Last night I dreamed that I was waiting to be served in a res- 
taurant. I waited an extremely long time and became very impatient. 

Interpretation: These two dreams inform us that the dreamer is growing impatient and 
contemplates direct action to satisfy her sexual need. The embarrassment is a twinge of 
conscience for having libidinous thoughts. 

Dream 63. I dreamed my husband was home. We were driving to a picnic (on the 
beach) and we had a carload of people. I kept praying that I wasn't dreaming, that it 
was true that he was home. I kept telling myself it must be so because it was so real. 
I was disappointed when I awakened and found it was just a dream. 

Interpretation: This dream represents the best solution for her conflict, namely, the 
return of her husband. 

Dream 64. I dreamed that I was in Fort Smith, Ark. I was at some sort of a party 
and it was in the woods. I suddenly saw my husband. Of course, he kissed me and then 
we sat down to talk. He said he was bringing some German prisoners over from Germany 
and he didn't have long to stay. I noticed that he wasn't wearing his wedding ring. I 
asked him if he had been going out with other girls and he said that he had. I asked him 
if we could go for a walk to get away from the people and to talk. Just as we started for 
the walk, I awakened. 

Interpretation: This is a nice rationalization of an impulse to be unfaithful. If the 
husband were not true to the dreamer, it would excuse her infidelity. 

Dream 65. I dreamed that my husband was dead and was in a suitcase in my closet 
at the dormitory. My roommate and I were frightened when we found him. The under- 
taker took him (suitcase and all) to a theatre and placed him up where the projector 
ordinarily is placed. I was sitting there with him crying while at the same time there was 
a wedding taking place on the stage. The bride was a friend of mine (a red-head) and she 
had on a pink wedding gown. As I remember, my husband wasn't dead, but he was 
"kidding" me. I might mention that I quite often dream that my husband is dead. 

Interpretation: Under the circumstances it would be better if her husband were dead, 
since this would leave her free to marry another man. The wedding represents her own 
remarriage. This interpretation is supported by the color of the wedding dress, which 
would not look well on a red-haired person but which would be becoming on the dreamer, 
who is blond. This solution, i.e., the death of her husband, is not acceptable to her, so she 
treats it as make-believe. 

Dream B6. I dreamed that I was talking to my brother-in-law and he suddenly turned 
into my husband. 

Dream By. In my dream, my cousin and I were riding and then we suddenly stopped 
to wait until a helicopter came along to pick us up. I believe I dreamed that we were 
taken in the helicopter (horses and all) to another trail where we continued our ride. 

Dream B8. I dreamed that my brother and I went to a small restaurant to get some- 
thing to eat. Dr. H. was the cook there and he was making waffles. Then he suddenly 
was sitting in a living room and a woman was there. I introduced my brother to him and 
asked if the woman was his wife. He said, "yes"; but then I remembered that I had met 
his wife and this woman was very definitely one I had never seen before. 

Interpretation: Although desiring male companionship and love, she cannot be pro.- 


miscuous. A brother, brother-in-law, cousin, or teacher are respectable substitutes for 
her husband. B8 has interesting possibilities. It may mean that she is trying to ra- 
tionalize her own conduct by projecting infidelity onto a respected teacher or that she is 
attracted to the teacher and wishes him to be unfaithful to his wife in order to justify her 
own deisre to promote an affair with him." 

An attempt was made to test the validity of the interpretations by 
subsequent discussions with the dreamer. While Hall is extremely 
cautious in his claims for validity, he has shown without much doubt, 
that a series of dreams do enable one to obtain a fairly good picture of 
conflicts that belabor dreamers. These findings are in disagreement 
with the tenets of some psychoanalysts. 

There is one point in connection with the dreams of psychoneurotic 
patients that should be mentioned. Some hysterical conditions seem 
to be produced as a result of vivid dreams. For example, functional 
paralysis of the hand following a vivid dream about letter writing or 
functional blindness following a dream of looking at a strong arc light 
may theoretically occur. At least Janet reports similar instances. 
The probable explanation is that some emotional factor dissociated in 
normal waking life, subsequently influences the dream. The recall of 
the dream or the reassociation established in the dream now makes the 
emotional state operative in normal waking life. The other explanation 
is that the dream is imaginary or that the falsification of memory for 
time is such that the whole thing is projected into the waking state. 


The skepticism of the phenomena of hypnotism existing among the 
uneducated as well as the educated can be well understood in view of 
the fact that their enlightenment has been obtained from observations 
of stage performances. These performances are usually veiled in mysti- 
cal rites and the processes involved are no better understood by the 
hypnotist than by his audience. The seemingly impossible tasks per- 
formed by hypnotized subjects are magnified in the minds of the on- 
lookers since they do not know the capabilities of the unhypnotized 
individual in making the same performances. Many physicians and 
psychologists have been similarly tricked into believing that the hypno- 
tized subject possesses some unusual power. One of the stock per- 
formances is to show a hypnotized subject four or five filing cards con- 
taining no apparent identification marks and to suggest to him that a 
picture of an animal is on each card. After these have been presented 
they are shuffled and the subject picks out the correct card on which the 


picture of each animal supposedly occurred. The cards had been 
previously marked lightly on the back so that they could be identified 
by the hypnotist or another person but in such a way that no clues were 
afforded to the subject. How is it accomplished and can an unhypno- 
tized person do it? The supposition is that the hypnotized subject has 
increased visual acuity, but then almost every one else has similar 
ability. The average person can do the task successfully since usually 
there are minute texture differences which can be perceived when the 
attention is focused on them. No one need question the authenticity 
of hypnosis. The statements of reliable experimenters, who do not 
have the charlatan's incentive of money and notoriety, and of the sub- 
jects themselves are all the proof necessary. It is not implied that all 
the claims of the experimenters are to be accepted without question or 
reservation since we will show later in this chapter that some of the 
claims are highly improbable in light of our knowledge of physiology 
and neurology. 

The very antiquity of the practice makes it a topic of considerable 
interest. 2 An Egyptian papyrus dating about 3000 B.C. has been 
discovered in which is set forth the procedure of modern hypnotism. 
The Medes, Chaldeans and Indians (Asiatic India) were very familiar 
with the hypnotic state. The methods have probably been handed 
down through the priests of Egypt, the Persian Magi and the Levites. 
The temple sleep induced by these priests was likely hypnotic. The 
Romans and Greeks at a later date were found to engage in the practice. 
From these sources it spread throughout Europe until Mesmer in 1774 
conducted some experiments and later set forth the theory of Mesmer- 
ism. Later investigators including Charcot, Bernheim, Liebeault, 
Krafft-Ebing, Forel, Beaunis and La Fontaine took it up. The latter 
introduced it into England, where Braid undertook a serious investiga- 
tion of Mesmer's theories. It found its way into America; the practice 
of hypnosis in this country was kept alive by Quimby, Gumes, Suther- 
land, and Beard. 

A discussion of hypnosis leads to a certain amount of overlapping 
with the topic of waking suggestion, since the hypnotic state is initiated 
in the waking state. Likewise, there are some factors common to both 
sleep and hypnosis that are a source of confusion. The relation of 

2 Moll and Bramwell have written excellent books dealing with the field of hypnotism. 
Although the books do not contain any recent experimental work, they bring together 
the early work on the topic. More recent books by Hull and Estabrooks are also recom- 


sleep, hypnosis and waking suggestion will be taken up later in this 

There are certain facts which will be presented in relation to the 
method of securing responses to suggestion. It is necessary to remind 
the reader again that the individual who has not been hypnotized must 
first be led to respond in the normal waking state. If you ask an in- 
dividual to mail a letter, stimulation of the auditory and visual receptors 
results in the sequence of responses necessary for carrying out the re- 
quest. You may say, and correctly so, that suggestion is not involved. 
If you state in the presence of the same person that you have a letter 
which should be mailed, and the sequence of responses is made which 
results in mailing the letter, is suggestion involved? In common 
parlance it would be called a hint or suggestion. How do the stimuli 
and responses differ in the two situations? The same receptors are 
stimulated and the same effectors are active in the total process. The 
main difference lies in the ideational aspects of the two situations which 
in turn are influenced by previous experience. Again you may ask is 
this related to hypnosis? The question is pertinent and the answer is 
affirmative. If one volunteers to be a subject for an hypnotic experi- 
ment, the past experiences and ideational processes at the moment 
determine to a certain extent at least whether the suggestions given will 
be complied with. The nature of the suggestion, as well as the "mental 
set" of the subject, are important in inducing the more complex phe- 
nomena of hypnosis. Let us first consider the types of stimuli usually 
employed. These may be divided for convenience into groups which 
conform to the predominant types of modal stimuli. 


Visual stimulation is one of the historical methods and is still in 
vogue. The use of moving stimuli to attract attention and hold it is 
one of the outstanding characteristics of advertising media. This 
method has been carried over into the field of waking suggestion for 
inducing hypnosis. A flashing light and revolving glass cut in such a 
manner that light is reflected have been employed. Opposed to the 
moving stimuli, the fixation of the gaze on a bright light, on a highly 
polished reflecting surface, and on the experimenter have been utilized. 
These stimuli are especially effective in bringing about the closing of 
the eyelids, although they are ineffective for some subjects. The 
efficacy of these stimuli is explained by certain anatomical and func- 
tional factors. When these stimuli are used, they are presented slightly 


above the level of the eyes. In order to fixate the object the eyes need 
to be raised, and this is the position of the eyes during sleep. The 
result is that the habitual sequence would require eyelid closure; and if 
appropriate ideation accompanies this, sleep may follow. The objec- 
tion may be raised that simply gazing at a point or a light will not nor- 
mally produce these reactions. Unless the visual stimuli are reinforced 
by other stimuli or ideas, there is a high probability that nothing will 
happen. Appropriate auditory stimuli, such as, "you feel drowsy, the 
eyelids are getting heavy, you are going to be hypnotized," repeated 
continuously, have their effects. 

This brings to the fore the use of auditory stimuli per se. Most 
writers suggest the use of monotonous sounds such as the repetition 
of the same sentence or phrases, counting, the ticking of a clock or a 
metronome. Certainly no one believes that listening to a clock tick 
without the proper attitude on the part of the subject will produce 
hypnosis. In conjunction with visual and tactual stimulation, clock 
ticks, accompanied by the belief in their influence, will induce the 
phenomena. One subject whom the writer had attempted to hypno- 
tize but who could not be thrown into the trance state by visual fixation 
and the usual verbal stimuli, however, when left alone for about five 
minutes with the instructions to listen very carefully to the ticking of a 
watch placed behind him was found in a fairly deep hypnotic state 
upon the writer's return to the room. Estabrook's graphaphone record 
for inducing hypnosis and the hypnotization of people listening to the 
radio indicate that auditory stimulation alone will suffice with the proper 
rapport. The use of the word sleep in inducing hypnosis has caused the 
writer considerable difficulty since the actions required later of the 
subject are not compatible with his ideas of what one does while asleep. 

Visual and auditory stimuli augmented by tactual stimuli will prob- 
ably be more effective than either used alone. Stroking the forehead, 
gently stroking down over the eyelids and face, and stroking of the 
limbs, are the tactual stimuli most frequently utilized. Slight touching 
of the eyelashes tends to close the eyelids and when reinforced by the 
statement that the eyes are going to close, the movement likely will 
follow. These stroking movements, in addition to aiding muscular 
relaxation, are part of the ritual carried over from Mesmer's notion of 
"animal magnetism." It was by these means that the flow of magnet- 
ism was transferred from the hypnotist to the hypnotee. Although 
the theory had been disproved, the ritual still survives and serves a 
useful purpose for some subjects. 


We cannot say, because of limited knowledge, that any one type of 
stimulation is more effective than any other. The type that is most 
effective for one patient may not be effective for another. In general, 
all of the methods should be combined with emphasis placed on the 
type that seems to be productive of results for the particular subject. 
The usual procedure is to have the subject recline on a couch or relax 
in an armchair. Explain to the subject that you would like his cooper- 
ation and something of the results which can be obtained. Caution 
must be exercised in what the subject is told will happen, if experi- 
ments are to be carried out, since this will influence his behavior. Have 
him gaze for a brief period at an object held in front and slightly above 
the level of the eyes. Tell him that he will be relaxed, calm and com- 
fortable. Gently stroke the eyes and face and add the suggestion 
that his eyes are getting heavy, that they are closing somewhat. Con 
tinue talking in a smooth even tone, suggesting relaxation, closing ol 
the eyes and deep breathing. Usually the eyes will close; now suggest 
opening the eyes and closing them more rapidly. From this point on 
the procedure varies with the degree of hypnosis desired. 

The author has found it desirable in most cases to open the eyes and 
have the subject stand. Again close the eyes and suggest swaying. 
When the eyes are closed, there occurs involuntary swaying to which the 
subject pays little attention. If the attention is directed to the swaying 
by the suggestion that the subject is swaying this will be interpreted by 
the subject as having been produced by the suggestion. Similar tricks 
may be employed to build up the subject's belief. If the arms are 
extended across the front of the body with the ringers interlaced and 
touching the back of the opposite hands, there is some difficulty in 
pulling the hands apart. This is due to the size of the knuckles. When 
the subject is told that he will have difficulty in separating the hands 
and actually finds such to be the case, further belief and expectancy is 
established. Suggestion of rigidity of the arms and the body will 
probably be accepted. Some subjects, however, are not amenable to 
any of these methods. 

Jastrow (635), Friedlander (636), Kauffmann (637), and Schilder 
(638) have used narcotics to reinforce the suggestion of sleep. This 
raises the question whether it is due to the action of the narcotic on 
the central nervous system or whether it is simply another method 
of establishing credulity. The writer is inclined to the latter view since 
several subjects who have resisted the other methods have succumbed 
when allowed to inhale what they thought was an anesthetic but which 


in reality was the odor from a fountain pen. Baernstein's 3 check on the 
influence of scopolamine hydrobromide (truth serum?) on enhancing 
the swaying response showed that the drug did not influence all of the 
subjects. Those subjects that were normally suggestive were found to 
be more suggestible after an injection of ^^ of a grain of the drug in 
solution than after an injection of a similar quantity of sterile water. 
Subjects whose knowledge of physiology is limited will sometimes 
respond to the statement that the reduction of circulation of the blood 
to the brain produces sleep and hypnosis, if one proceeds to press the 
fingers on appropriate portions of the neck. The subject should always 
be made to place his fingers on the artery so that he can feel the pulse 
beat. The foregoing account presents the essential facts for the pro- 
duction of hypnosis. The timing and the sequence of the suggestions 
given are of equal if not greater importance. No general rules can be 
laid down in regard to these matters since each subject presents a differ- 
ent problem in his attitude toward the occurrence of the phenomenon. 
Experience with a variety of subjects enables the experimenter to gauge 
the optimal time for new suggestions. 


In the literature on suggestion, reference is made to prestige sugges- 
tions, nonprestige suggestions, waking suggestions and hypnotic sug- 
gestions. Prestige suggestions are those in which the suggestion is 
given in a direct form by another person or by mechanical means such 
as a phonograph. You are going to sleep; your eyes are closing; and 
you are going to be hypnotized; are typical examples of direct sugges- 
tions. These suggestions may be given either in the waking state or in 
the hypnotic state. Nonprestige suggestions are those in which a 
situation is set up so that an expected stimulus may occur but does not 
actually take place. A typical example of this kind of suggestion is 
found in the creation of illusions of warmth and pain. The subject feels 
pain when an inductorium vibrates; but when a short circuiting switch 
is closed and no current is imposed on the subject, he may again feel 
pain provided the original stimulus was near the limen. There is, of 
course, no reason to assume that these suggestions would not work just 
as well in hypnosis although they are usually referred to as nonprestige 
suggestions only when administered in the normal waking state. The 
distinction between waking suggestions and hypnotic suggestions is an 

3 Reported by Hull in Hypnosis and Suggestibility. Appleton Century Co., 1933. 


artificial distinction since all suggestions are administered in a waking 
state, otherwise the subject would in general not respond to them. 


We shall now consider some factors related to nonprestige suggestions 
administered in the normal waking state. Illusions have been used 
extensively as measures of normal suggestibility. Size-weight illusions, 
illusions of movement, illusions of smell, and illusions of warmth can be 
produced in children and adults. Murphy (639) has presented an ex- 
cellent summary of this work in his book on Experimental Social Psy- 
chology. On the illusion of seeing a ball thrown into the air Triplett 
(640) reports that about 50 per cent of 165 children in the fourth to the 
eighth grades saw the ball thrown into the air. Small (641) found that 
73 per cent of school children smelled odors when water was sprayed into 
the air and about 76 per cent saw movement of a toy animal when a 
crank was turned which supposedly moved the toy. Guidi (642) 
found that on warmth illusion children ranging from 6 years of age to 
15 years of age were suggestible in percentages ranging from 50 to 33 
per cent. These findings are in accordance with those of Gilbert (643) 
on size-weight illusions. He reported that suggestibility increased up 
to about the age of 9 and decreased from that point on. Heron (644) 
from a warmth illusion similar to that of Guidi, found that 28 college 
students from a total of 54 (approximately 51 per cent) accepted the 
suggestion of heat. The women were slightly more suggestible than 
the men. 

Do these varied experiments actually support the thesis that sug- 
gestibility decreases with age? The answer is not clear cut. On 
warmth illusions the percentage found by Guidi was about 50 for the 
lower age groups which corresponds with Heron's figure of 51 for college 
students and also compares favorably with the percentage found by 
Triplett on the ball being tossed into the air. Small's figures of 73 and 
76 per cent for illusions of movement obtained on children are probably 
higher than would be obtained on adults. Likewise the size-weight 
illusion can be established more often in children, since their experience 
with weight of objects is more limited than that of adults. That 
children are suggestible cannot be denied and that they are more sug- 
gestible than adults is probably true, but caution must be used when 
making inferences from a specific type of suggestibility to general 

In regard to the relative suggestibility of men and women, the experi- 


mental data show that for specific types of suggestion or situations, 
women are more susceptible than men. Warner Brown's (645) study 
of sex differences in suggestibility is the most extensive and carefully 
controlled piece of work thus far accomplished. The first 4 experiments 
invoke a least perceptible sensation or rather, they are designed in such 
a way that the subject imagines a sensation in the absence of specific 
stimulation but under circumstances appropriate for the occurrence of 
the sensation. In his odor test, the subject was given these instruc- 
tions: 4 

It is the object of this experiment to measure the delicacy of your sense of smell. 

The experimenter will let you smell a comparatively strong sample of each of three 
odors peppermint, wintergreen, and ethyl alcohol. 

You will then be given ten bottles in succession. You are to smell each of these 
carefully and report in each case whether you smell one of the odors you have just sampled, 
some other odor or no odor at all. 

The ten bottles actually contained only distilled water. 


You will see a set of small cork weights, some of which are so light that they cannot 
be felt at all. It is the purpose of this experiment to find the lightest of this set of weights 
which you can feel on the top of the middle finger. When the experimenter says "ready" 
you are to see whether you can feel the weight or not and report to the experimenter 

The subject was then shown that one of the corks aroused no sensa- 
tion of weight, whereas a somewhat larger one would. The hand of the 
subject was then shielded from his view and only the imperceptible 
corks used as stimuli. 


It is the purpose of this experiment to determine the smallest amount of heat which 
you can feel with your finger. 

Wait until the box has been heated by the electric current for one minute. Then let 
the index finger follow the indicator slowly into the hole until you feel the least per- 
ceptible warmth from the heated coil within. 

If you do not feel the warmth the first time allow the current to heat the box for 
another minute and then try again. If you still fail to feel the warmth, it means that 
your sense of temperature is not sufficiently delicate and the experiment must be given up. 

The box was so arranged that no heat was transmitted to its interior 

4 All of the quotations appearing in the following section are reprinted from W. Brown, 
Individual and Sex Differences in Suggestibility, Univ. of California Press. 


and the whole setting was favorable for establishing the idea that the 
box was heated. 


It is the purpose of this experiment to measure the weakest induced current which you 
can feel passing from one finger to the other. 

You are to sit with the first and second fingers of your left hand dipped in the glasses 
of water which contain the electrodes. The experimenter will start the current through 
the primary coil and then pull the secondary coil slowly up until you feel the current 
distinctly. This is merely to acquaint you with the working of the apparatus. 

The experimenter will then push the coil back and start it up again very slowly. You 
are to keep a sharp lookout for the first faint shock and as soon as you are sure that 
you feel it tell the experimenter to stop. 

In case you do not feel the current soon enough, the experimenter may again return 
to the starting point. The experiment may be repeated two or three times at the dis- 
cretion of the experimenter. 

The subject was shocked when the apparatus was first demonstrated. 
For the control work the coil of the inductorium was moved but the 
current to the electrodes was cut off. 

The results of these four experiments indicate that individuals vary 
in the way in which they yield to suggestion. The illusion of odor was 
established in 90 per cent of the subjects; touch in 72 per cent; shock in 
78 per cent; and heat in 60 per cent. Intercorrelations of the test per- 
formances were positive although small, which indicates that suggesti- 
bility is a trait which functions in tests having certain characteristics 
in common. Women were on the whole more suggestible than men. 

The student should be able to form an adequate idea of the nature 
of the tests from the above presentation. In the subsequent section 
only one type of test will be taken up which illustrates the general mode 
of procedure. 

The next four tests involve the illusory perception of a change in 
brightness, pitch, size or motion. Actual changes were first demon- 
strated and the subjects were then instructed to indicate when they 
thought a change had occurred although no change was made. These 
instructions were given for the change in size. 

It is the object of this experiment to see how small a change in size you can notice. 
You will see a bright area on the screen. This can be made gradually larger or smaller. 
Watch it closely and as soon as you see any change of size tell the experimenter whether 
it is increasing or decreasing in size. 

Similar instructions were given for brightness, pitch and motion. 
Fifty-five per cent yielded to the brightness illusion in 10 seconds; 41 per 
cent to pitch; 68 per cent to size; and 61 per cent to motion. In respect 


to suggestibility of men and women these tests yielded the same results 
as the previous tests. 

Two tests originally designed by Binet were included in the battery. 
Suggestibility in these tests was introduced by having an appreciable 
increment in weight or in size of lines for the first 4 or 5 judgments 
and thereafter no actual increment. For example, in the weight series 
the first 5 boxes weighed 20, 40, 60, 80 and 100 grams, all of the others 
weighed 100 grams. Since the subject expected the increment to con- 
tinue, there was a tendency for the next 100 grams weight to be judged 
heavier. Of 140 subjects tested, only 2 were unsuggestible to the weight 
change and of 137 tested on progressive lines, only one was unsuggesti- 
ble. The women were more suggestible than the men. 

Five tests involving recognition of form, recognition of position, 
recognition of size, memory for pictures and an Ink Blot test for imag- 
ination were utilized as the next step in procedure. The principle of 
the first 4 of these tests is to present a pattern or form briefly for the 
subject to see. Some details in the pattern or form again presented are 
altered and the instructions are designed in such a way as to bring about 
the tendency to identify the second pattern or form with the first. On 
the Ink Blot test the directions were as follows: 

Individuals differ greatly in the fertility of their imagination. It is the aim of this 
experiment to find out how many things will be suggested to your mind by a senseless 
ink blot. This particular blot may make you think of some kind of animal, or of any 
number of other things. See how many things you can write down in two minutes that 
the blot might be a picture of. 

The number of subjects affected by the Form Test were approxi- 
mately 70 per cent; by the Size test 75 per cent and by the Position test, 
60 per cent. In regard to sex differences the women seem more sug- 
gestible on the Recognition of Form Test, the Position test and Ink 
Blot Test. There is no reliable difference on the other 2 tests. 

The remainder of the battery of tests of suggestibility are based upon 
the principle that if a subject is told what the usual judgment made 
by others is, or what factors in a situation tend to make for error, he 
will modify his judgment to conform to the stated average or to com- 
pensate for the error factors. These tests are similar in some respects 
to prestige suggestions. 

The tests are listed below: 

1. Size-Weight Illusion 

2. Miiller-Lyer Illusion 

3. Estimation of Distance 


4. Estimation of Weight 

5. Preference for Proportions of Rectangle 

6. Preference for Proportions of Triangle 

7. Preference for Proportions of Cross 

8. Preference for Proportions of Divided Line 

9. Preference for Color 

10. Preference for Tone 

11. Preference for Color Combination 

In 5 of the above tests, Brown found that women were more sug- 
gestible than men; in one more they were probably more suggestible; in 
one, men were more suggestible than women; and probably in 2 others 
the last relation holds. 

We may conclude that in most of the traits tested women were more 
suggestible than men; and although intercorrelations of the tests yield, 
on the whole, low positive results it is unsafe to say that suggestibility 
is a unit trait. It may probably be true that a few individuals who are 
suggestible in one test will also be suggestible in others, and it is also 
true that other individuals will be found who are not uniformly sug- 
gestible. This is in agreement with Chojecki's (646) conclusions on a 
group of 60 college men and women. He found no correlation between 
suggestibility on warmth illusion, progressive line test and a change in 
sensitivity after a magnet had been applied to the finger. Data derived 
from experiments by Aveling and Hargreaves (647) show that there is a 
low positive intercorrelation among the several tests of suggestion 
employed by them. Such illusions as warmth, progressive lines, and 
progressive weights give a maximum correlation of +.32. 


All people do not respond equally well to waking suggestion, and 
consequently we would expect that some people would not be easily 
hypnotized. Specific statements such as women are easier to hypnotize 
than men; children are easier to hypnotize than adults; weak volition 
is necessary; or emotional imbalance such as is manifested in hysteria 
favors the process, have in the past not been founded on fact. The 
susceptibility to hypnosis is determined by at least 3 factors: (a) the 
subject's previous experiences, (b) the hypnotist and (c) the method 
of induction. These three variables account for the wide divergence 
in statements made. Serog (648) claims that 100 per cent of normal 
healthy men are susceptible to some form of hypnosis. Other writers 
give figures ranging from 10 per cent up to 100 per cent. 

Whether people who are unwilling to be hypnotized can be hyp- 


notized has never been satisfactorily settled. The writer has succeeded 
in hypnotizing 2 college students who insisted they could not be hyp- 
notized, after about 12 sessions of several hours each. They were 
willing to cooperate but insisted that they could not and would not be 
hypnotized. After the initial hypnotization a wide variety of phen- 
omena could be produced. The inference must not be made from this 
experiment that all individuals can be hypnotized against their will. 
Unless they are willing to take the time and submit themselves to the 
process, nothing can be accomplished. Careful selection of subjects will 
increase the percentage; repeated attempts to hypnotize will also yield 
an increased percentage and change of hypnotists will cause some 
heretofore unsusceptible subjects to become susceptible. Prince (649) 
and Haupt (650) believe that even in the same individual the sus- 
ceptibility varies from zero to TOO per cent at different times. 

Hull (651) in summarizing studies by Barry, Mackinnon, and Murray; 
White; and Jenness, concludes that a number of prestige tests in the 
waking state are diagnostic of whether the subject is susceptible to 
hypnosis. The response to suggested arm movement and suggested 
postural change has been correlated with rate of lid closure and the 
production of other hypnotic phenomena. On the contrary, the fre- 
quency distribution curves of response to waking suggestions of hand 
levitation, to waking suggestions of electrical shock, and to waking 
suggestions of a swinging pendulum are U shaped. These U shaped 
curves do not correspond to the frequency distributions found for 
responses in hypnosis which in some cases are linear. Body sway and 
illusion of heat show a high correlation with susceptibility to hypnosis, 
according to Furneaux (652). One might argue, therefore, that the 
phenomena of indirect waking suggestion, direct waking suggestion and 
hypnosis are dissimilar and that the relationship is relatively slight. 
Such a conclusion is based on data obtained from dissimiliar groups of 
people, dissimiliar techniques and different hypnotists and should be 
accepted with maximum reservations. 

In our previous discussion of susceptibility to waking suggestion, 
v/e showed that susceptibility to the various forms of nonprestige sug- 
gestion was not equal or uniform. Hull finds, however, that prestige 
suggestions of various types show a fairly high degree of intercorrelation 
and also correlate with susceptibility to hypnosis. He arrives at the 
conclusion, which the writer suggested earlier in this text, that direct 
waking suggestion and hypnotic suggestion may be encompassed in the 
same definition. 

Age differences are probably important in determining susceptibility 


to hypnosis. We might anticipate that a study of this factor would 
reveal that the tendency conforms to other types of suggestibility. 

Other traits such as submissiveness, introversion, extroversion, ego- 
ism, and neuroticism have been mentioned as essential characteristics of 
good hypnotic subjects. Davis and Husband (653) have attempted to 
discover if such relationships exist. They correlated the scores made on 
Thurstone's Personality Schedule, Laird's so-called Introvert Test, 
Watson's Test of Fairmindedness and the Pressey X-O Test for Affective 
Reaction with susceptibility to hypnosis. They set up an arbitrary 
scale of susceptibility of 5 steps, which ranged from unsusceptible to 
the somnambulistic trance. The validity of this procedure may be 
questioned since the ideation and belief on the part of the subject mark- 
edly influences the type of phenomena exhibited. No significant cor- 
relations were found between the test scores and susceptibility. In 
other words, individuals who were neurotic, introverted or easily in- 
fluenced emotionally were no better subjects than those who did not 
possess the traits. The Rorschach test has been employed by Sarbin 
and Madow (654) and Brenman and Reichard (655) to determine the 
relationship between personality characteristics and hypnotizability. 
The former investigators held that the W/D ratio separated the good 
hypnotic subjects from the poor hypnotic subjects. "W" refers to the 
situation in which the ink blots are responded to as wholes and "D" 
to the situation in which the response is made to details of the blots. 
The latter investigators do not agree in their findings. 

Baumgartner, (656) working along similar lines, attempted to deter- 
mine whether the suggestion of falling forward when one stands up with 
the eyes closed, shows any relation to such character traits as beauty, 
optimism, honesty, sympathy, sweet temper, tactfulness, positive 
suggestibility and negativism. These character traits were assigned 
values by the supervisors. Small positive correlations were found 
between the amount of swaying and sympathy, sweet temper, tactful- 
ness, and suggestibility as rated by the supervisors. Williams (657) 
applied suggestions of postural swaying to catatonic, paranoid and 
manic depressive patients. The latter patients were in the manic 
phase. The paranoid and manic patients were not found to differ 
to any great extent from normals but the catatonics showed definite 
negative responses. Some cases exhibited definite overcompensation 
in the attempts to avoid the effects of the suggestions. 

Davis and Husband (658) found no significant sex differences in 
susceptibility to hypnosis in a group of 55 college students. The notion 


that certain characteristics favor the susceptibility to hypnosis seems 
to be without foundation. Emotional disturbances are not necessarily 
favorable for inducing hypnosis since an excited patient or a drug addict 
in need of his drug is exceedingly difficult to hypnotize. The writer 
has found two types of individuals usually hard to hypnotize; (i) those 
strongly averse to the procedure and (2) those overanxious. The person 
who is in a state of indecision seems to be the most desirable one to 
select. Brenman and Reichard have found similar results through 
the use of the Rorschach. In these individuals, negativism and anticipa- 
tion do not prevent the suggestion from being expressed in ideomotor 


The psychoanalytic doctrine has been utilized for explaining certain 
factors in the hypnotic procedure. Among these has been the explana- 
tion of the type of person who will likely make the best hypnotist. 
Ferenczi's (659) theory incorporates the doctrine that every successful 
reaction to suggestion takes place because the subject regresses to an 
infantile state in which the infantile attitude toward the parent of the 
opposite sex is assumed. McDougall (660) in criticising this theory 
states that: 

If we take the theory seriously, we should expect to find that the normal man is sus- 
ceptible only to the cooperative or "maternal" form of suggestion; or the normal woman 
only to the domineering or "paternal" form. But there is no indication, and no claim 
is made, that any such rule holds good. 

This brings us to a consideration of whether the domineering hypno- 
tist is more successful than the nondomineering hypnotist. Likewise, 
is a man or a woman more successful? 

Answers to the questions are pure speculation. Unquestionably 
some individuals succeed in hypnotizing more often than others. The 
personality that is successful in controlling the activities of individuals 
normally varies. A glance at our industrial and military leaders will 
convince the worst skeptic. The education and other qualifications of 
the subject enter into the problem. The greatest assets of a hypnotist 
are experience and prestige. Experience dictates the opportune time 
for giving new suggestions and enables the experimenter to recognize 
the signs of acceptance or rejection. Some suggestions that are not 
immediately accepted can be reworded so that resistance to their ac- 
ceptance will not be built up. Prestige, while not proved by controlled 
experiments, plays a large role. A subject who has seen the hypnotist 


give a successful demonstration is likely to be influenced by the fact that 
it had already been done. Well-known facts derived from the field of 
advertising support the notion of prestige. The largest, the best and 
the strongest are successful appeals in influencing people to buy com- 
modities. The writer has tried the following experiment. Student A 
hypnotized in the presence of student B was unsusceptible to B in spite 
of the similarity of methods employed. This is not true, of course, 
for all subjects. The difference apparently lies in the prestige of the 
instructor as contrasted with that of the student hypnotist. 


Certain phenomena related to hypnosis have been discussed under the 
names of waking hypnosis, and auto-hypnosis. The term waking hyp- 
nosis has been introduced into the literature to account for many of the 
phenomena that occur from suggestion without the direct suggestion 
of sleep or any of the symptoms of sleep. Wells (66 1) has succeeded 
in producing anesthesia of the hand, cure of headache, and amnesia, in 
waking hypnosis. This form of procedure does not add anything to our 
knowledge of the mechanism involved. All that has been accomplished 
is to show that by modifying the instructions some of the more complex 
actions can be produced without the intervention of a series of steps to 
build up the credulity of the subject. Certainly, all hypnosis is waking, 
to the extent that the initial suggestion of closing the eyes is given while 
the subject is awake. It is not surprising then that some subjects will 
experience an initial loss of sensation if suggestions of this type are given 
first and especially if they think that anesthesia is one of the character- 
istics of the hypnotic condition. Wells seems to be questioning the 
validity of the different stages of hypnosis. 

Hypnosis has been divided by some authors into various stages which 
are separate and distinct states; the number varies with the particular 
author consulted. These may be referred to as light, medium, and 
deep hypnosis, or hypnoidal, cataleptic, and somnambulistic. These 
classifications of hypnotic pheonomena are grouped in accordance with 
the usual sequence in which they are produced or in accordance with 
the complexity of the phenomena. 

Davis and Husband, using the gaze fixing method and giving sugges- 
tions of eye closing, rigidity of arm and leg, total muscular rigidity, 
"glove" anesthesia, amnesia, a variety of hallucinations and post- 
hypnotic suggestions showed that 29 per cent of their subjects were 
susceptible to the hypnoidal state, 18 per cent to the light trance, 15 


per cent to medium trance, and 29 per cent to the somnambulistic 
trance. Their findings are interesting but are not conclusive, since 
another technique and another hypnotist may secure an entirely differ- 
ent ratio. It is probably safer to say that there are no distinct stages of 
hypnosis and probably no graded series of phenomena. The ease with 
which a given state can be induced is dependent upon numerous factors. 
Auto-hypnosis produced by auto-suggestion is the state in which ideas 
are accepted and acted upon in such a manner as to bring about phe- 
nomena similar to hypnotic phenomena. Whether auto-suggestion is 
essentially different from hetero-suggestion is not agreed upon by theo- 
rists. The writer is inclined toward McDougalPs theory in which he 
maintains that auto-suggestion is really hetero-suggestion. Hetero- 
suggestion depends upon stimulation of some kind from the environ- 
ment or from another individual; these stimuli may directly result in 
response or they may, through association, arouse ideational factors 
that result in reactions of a particular sort. In auto-suggestion, the 
external stimuli, especially those from another individual, are eliminated, 
but a wide variety of feelings and proprioceptive stimuli are still opera- 
tive. These may result in direct activity or they may arouse ideational 
factors which produce the behavior normally ascribed to auto-hypnosis. 
If some one happens to mention that it is 6 o'clock and almost dinner 
time and I proceed to leave my office for home, is this reaction essentially 
different from my going home if I happen to feel hungry about 6 o'clock? 
There are certain differences in the neural pathways involved, but the 
functional processes are not unlike. The reaction of the individual 
who believes in the repetition of Coue's formula, "I am getting better 
and better" is not essentially different from the reaction of the individ- 
ual who accepts the physician's word that he is getting well. The 
medium who goes into a trance or the hysterical patient who has func- 
tional paralysis is reacting to stimuli in a manner determined by the 
integration at the moment. We will have more to say about this topic 
in connection with our discussion of the theories of hypnosis. 


The physiological concomitants of hypnosis and the effects of hyp- 
notic suggestion upon physiological functions are of interest and must 
be understood before an adequate theory of hypnotism can be con- 
structed. Physiological changes accompanying hypnosis have not been 
adequately investigated. Some writers report changes without definite 
suggestions of such changes, but rarely do they state the exact nature of 

3 20 


their instructions. Casual observations on subjects indicate that some 
circulatory changes occur. Increased pulse rate and slight rise in blood 
pressure have been noted. These increases may be due to emotional 
excitement rather than to hypnosis, per se. Walden's (662) early 
plethysmographic study indicates a sudden short constriction of the 
peripheral blood vessels at the beginning of hypnosis followed by gradual 
dilatation until the end of the hypnotic sleep. At the instant of awaken- 
ing there is again a brief constriction. Pulse rate and respiration are 
slower; a steady slight fall in rectal temperature is observed; and the 
surface temperature is higher. The writer has found a decrease in 
systolic and diastolic blood pressure and a fall in the pulse rate as com- 
pared with the normal for a period of fifteen minutes. Jenness and 
Wible (663) have concluded the most extensive studies on cardiac and 
respiratory changes during hypnosis. They find no significant differ- 
ence between the normal state and hypnotic state in the absence of 
direct suggestions. They do find that respiration is increased with 
direct suggestion but that the cardiac rate is not. Beaunis (664) in 
1884 felt that muscular strength was lessened, although not uniformly, 
without definite suggestion to that effect. He also reports a decrease 
in auditory acuity of approximately 50 per cent without suggestion. 
Even if these changes are not brought about by the suggestion of sleep, 
relaxation, and similar suggestions, expectancy on the part of the sub- 
ject may play an important part. 

The influence of direct suggestion upon functions controlled by the 
autonomic nervous system has been the subject of a great amount of 
controversy. The autonomic system is partially under voluntary 
control. The sphincter muscles of the bladder and anus, erection of the 
glans penis, pulse rate, respiration rate, probably secretion of the stom- 
ach, and certain of the endocrine glands are subject to partial voluntary 
control. It is not unreasonable to suppose, then, that these functions 
can be modified and controlled to a certain extent by direct suggestion 
since the same neural mechanisms are involved. All that is accom- 
plished through hypnosis is the substitution of an unusual set of stimuli 
for the varied stimuli which alter the physiological processes. An 
increase or decrease in blood pressure, evacuation and retention of the 
bladder and bowels, digestion, kidney secretion, increase and decrease in 
temperature, blanching and flushing of restricted parts of the body, 
formation of blisters, rate of healing of tissue, secretion of the mammary 
and sweat glands, production and inhibition of menstruation, configura- 
tion by blanching or irritation of specific areas, and the weakening of 


the effects of adrenalin, pilocarpine and atropine have been reported. 
The production of these phenomena are usually taken as evidence that 
hypnosis, per se, has some extraordinary influence on the nervous system 
or that the nervous system is functionally altered in some respect. This 
conclusion is not necessarily warranted since most of the above phe- 
nomena can be brought about by a number of situations in daily life. 

Blood pressure changes are concomitant with emotional states, 
exercise, fatigue and even atmospheric conditions. In appropriate 
social situations both retention and evacuation of the bladder and 
bowels occur. We do not know, for example, just how long the sphincter 
ani can be contracted after the administration of a purgative. Luck- 
hardt and Johnson (665) have shown that the acidity of the stomach is 
about the same after the ingestion of a test meal, after a hypnotically 
suggested meal and after talking about a meal in the normal state. 

Temperature regulation seems to be one of the most difficult phenom- 
ena to explain; nevertheless, worry, excitement and even the continual 
remarks about the hot and cold weather probably have their effects. 
In regard to blanching, McDougall (666) reports a case of a subject who 
could voluntarily throw himself into a trance-like state in which his 
circulation was modified so that a needle thrust into his arm produced 
no bleeding. The formation of blisters and healing of tissue are normal 
events; we do not usually think of these things as subject to voluntary 
control. McDougall again mentions the formation of blisters by sug- 
gestion and cites Delboeufs work on healing. Delboeuf burned two 
similar areas on the forearms of a subject. He suggested that one area 
would heal rapidly and the other was left to heal at its natural rate. 
The reduction of inflammation produced by suggestion apparently 
brought about a greater rate of healing. Without questioning the ac- 
curacy of the observations, we need to have more details concerning the 
experiment so as to exclude the possibility that the subjects did not 
irritate the surface of the arm in the production of bliste* s or did not 
either aid or hinder the healing process of the burns. Jerdriassik (667) 
and Krafft-Ebing (668) are reported to have formed blisters which 
corresponded to the shape of an object or a letter pressed on the skin. 
The only criticism of the experiments that can be made is whether they 
had properly controlled conditions to rule out extraneous factors. 
Ullman (669) claims to have induced a secondary burn as well as her- 
petiform lesions in an hysterical subject through direct suggestion. 
Pattie (670) has reviewed all the literature on the topic of blister forma- 
tion through hypnosis. He reports experiments dating back to 1886 


and extending through 1927. His summary and conclusions still 
leave doubt concerning this fundamental problem, which should be 
cleared up by a thorough study. The mammary glands will secrete 
normally under proper stimulation and ideational factors so the same 
result could be predicted under hypnosis. The same applies to men- 
struation. Fear, warmth, cold and excitement all tend to influence 
this function. A critical attitude must be maintained in regard to 
configuration through blanching or cyanosis. The neural mechanism 
is such that control of gross portions of the body could be anticipated. 
Work by Lipkin, and others (671) has demonstrated that gross 
circulation changes in the periphery can be modified by hypnotic 
suggestion. They succeeded in relieving vasospastic symptoms and 
made observations of changes in capillary flow. Neural ramifications, 
however, do not conform to patterns. Almost all of the phenomena 
mentioned are influenced by normal waking conditions; hence it is 
not improbable that the reinstatement of these usual experiences either 
through hetero-suggestion or auto-suggestion, is adequate to account 
for the reactions. If the subject feels that the reaction is one that goes 
along with hypnosis, then the association processes are likely to lead 
him to situations that have previously evoked these responses. 


The variety of psychological phenomena that can be produced under 
hypnosis covers the entire field, including sensations, feelings, emotions, 
negative and positive hallucinations, amnesia, and almost the entire 
range of motor responses which the subject is normally capable of 

An increase, decrease and perversion of the sensations is easily dem- 
onstrated. Sensation for warmth, cold, touch will be denied by most 
subjects with appropriate suggestions. Apparent increased sensitivity 
is manifest in many of the hypnotized subjects' reactions. Threshold 
changes have been pointed out by some experimenters. Beaunis (672) 
reduced auditory sensitivity but could not increase it with suggestion. 
Travis (673) has indicated that in reverie there is a lowering of the thres- 
hold of auditory sensitivity. Whether pain is felt to any considerable 
degree when anesthesia is suggested is a question still not satisfactorily 
answered. Pain of major operations such as amputation of the leg, 
appendectomy, and of child birth has been successfully assuaged by 
hypnosis. Many experimenters have demonstrated the fact that the 
arm or hand of a hypnotized subject can be burned or cut without any 


observable signs. Nevertheless there is a sensation of pain, since if the 
subject is rehypnotized and told to recall his experiences he will state 
that pain was experienced. This simultaneous perception of and lack 
of perception of sensation is one of the most troublesome problems for 
psychology. How real is the anesthesia? Some writers contend that 
the anesthesia is no more real than the anesthesia of the person who has 
a tooth extracted without an anesthetic and with an air of bravado 
says it didn't hurt at all. The stoicism of the American Indians in the 
face of pain is well known, and hence some say that the hypnotized 
subject shows only marked discrepancy between the actual feelings and 
the manifestation of the feelings. The subject's own statement that a 
burn did not hurt should of course be given some weight. The experi- 
mental data are more to the point than these casual observations. 
Neutra (674), the German obstetrician, has observed that the post- 
operative and post-delivery shock is greater following hypnosis than 
following an anesthetic. This of course indicates that the feelings or 
sensations are just as strong as without hypnosis. Kroger and De Lee 
(675) in their report on the control of pain in childbirth seem to hold 
that there are no consequences attendant upon the use of hypnosis. 
The work of Dorcus and Kirkner (676) and Kroger and Freed (677) 
indicates that the painful cramps associated with dysmenorrhea can be 
alleviated to a marked degree of hypnosis. Similarly, the intractible 
pain associated with paraplegic conditions can be partially controlled 
by hypnotic suggestion, as has been shown by the former of these in- 
vestigators. Bechterev (678) maintains that the usual reactions to 
pain stimuli, i.e., change in respiration, heart rate and the pupillary 
reaction, do not occur with hypnotically suggested anesthesia. 

Sears' (679) carefully controlled experiments on facial expression, 
respiration, pulse activity and skin resistance show that these functions 
which are partly voluntary and partly nonvoluntary have different 
characteristics under normal inhibition than under hypnotic suggestion. 
Sears states, "That hypnotic anesthesia is in any sense a conscious 
simulation seems doubtful." Work by Dorcus shows that the galvanic 
skin resistance varies in a similar way for both the normal and hypnotic 
state. Anacusia, amnesia, and anesthesia hypnotically induced are 
followed by psychogalvanic reflex actions, whereas an anesthesia brought 
about by local injection of novocaine destroys the response. These 
responses are shown in plate II. 

Dynes (680) maintains that the cardiac and respiratory changes 
normally following sharp painful stimulation of the skin are reduced to 


a minimum. Pattie (68 1) has approached the problem in a somewhat 
novel way, and his findings furnish a better clue to the subjective state 
in hypnotically induced anesthesia than many of the other experiments. 
He compared the ability of subjects to discriminate the number of 
touches in the normal and in the hypnotic state when the hands were 
clasped either in the normal way or in the position of the "Japanese 
illusion." The "Japanese illusion" results in a confusion of knowledge 
concerning the hands. The hypnotic subjects experienced no difficulty 
in counting the number of touches on the fingers of the unanesthetized 
hand when the hands were clasped in normal fashion, but difficulty was 
encountered in suppressing the touches on the anesthetized hand in the 
"Japanese illusion" position. This experiment definitely shows that 
the hypnotic, anesthesia is not a genuine anesthesia but depends upon 
accurate perception of the stimulus if the subject even attempts to carry 
out the suggestion. 

Pattie (682) in another experiment on uniocular blindness hypnoti- 
cally induced found that he was unable successfully to produce the 
phenomenon. All of his subjects were eventually shown to be faking 
(perhaps not in the usual meaning of this term), since they were unable 
to pass complicated tests for visual malingering. 

A series of experiments by Dorcus (683) on nystagmus, the falling 
reaction, pupillary reaction to light and the production of colored after 
images, showed that in no case was there an alteration of the normal 
processes of response by hypnotic suggestion. A comparison of the eye 
movements following suggested rotation, with the eye movements 
following actual rotation, showed that the movements were not truly 
nystagmic but of the voluntary exploratory type. Similarly, the after 
images of suggested colors were appropriate only so far as the subject 
knew what the after images should be and could simulate them. When 
the situation was made complex, the after images were always those of 
the physical stimulus. The falling reaction following suggested rotation 
never took place until the subject had first had the experience from 
actual rotation. 

These experiments show rather conclusively that the suggestions do 
not produce the actual neurological patterns that are invoked by the 
physical stimulus. 

It is unquestionably tiue that the sensory thresholds may be raised 
by hypnotic suggestion, but that they can be lowered seems somewhat 
doubtful. No one has successfully demonstrated that visual acuity, 
auditory acuity, tactual acuity or olfactory acuity has been increased 


by suggestion. Apparent increases in acuity have been reported, how- 
ever. These measures have been founded on the observation of over- 
activity on the part of the subject to the same stimulus. Direction of 
attention to the task to be done and lack of knowledge of the waking 
performance of the same subjects accounts also for some apparent 

The production of emotions and feelings can be demonstrated by 
relating to the subject a sad story or a joke. Copious weeping and the 
appearance of dejection occur upon the suggestion of a death of an 
imaginary chum. Any commonplace story, even if it is not funny, will 
be reacted to in an hilarious manner if the subject is told that it is going 
to be funny. These affective states are more easily provoked if there is 
some semblance of truth in them or if they sound plausible. Levine, 
Grassi and Gerson (684) studied Rorschach protocols of an hypnotic 
subject in whom they had induced such emotional states as elation, 
depression, and apprehension. These protocols were compared with the 
protocols obtained under normal conditions. The records for the two 
states were sufficiently similar to show that the same basic personality 
was being observed but the "emotionally induced" records had features 
common to those found in clinical cases with emotional disorders. 
Simulated disorders without hypnosis are needed to ascertain the real 
effects of the hypnotic emotions. 

Positive and negative hallucinations of hypnotized subjects have been 
witnessed by almost all spectators at hypnotic demonstrations, Im- 
aginary animals, imaginary sounds, and imaginary objects and people in 
the environment will be treated as though they exist, if a positive hal- 
lucination is induced. Observing the behavior of subjects under such cir- 
cumstances raises the question as to whether the subject has full realiza- 
tion of the deceptions practiced. 

Admission of knowledge of deception can be brought about under 
rehypnosis and sometimes in the waking state. On the contrary, 
certain performances suggest that the hypnotee is unaware that he has 
had hallucinations. The writer has caused a hypnotized subject to 
walk into the wall from which he sustained a nosebleed when told to 
walk through an imaginary door in the wall. Other subjects, seem 
actively to avoid walking into objects in the environment when told 
to walk down an aisle rilled with chairs. 

This brings up a consideration of the problem of how far a hypnotized 
subject can be made to conform to the hypnotist's instructions. Re- 
ports of subjects stabbing a dummy with a knife or dagger, firing blank 


cartridges at a person who has done them an injury and administering 
what the subject believes to be poison in tea or coffee cannot be doubted. 
Similarly, the commission of immoral acts by some subjects can be 
expected. The experimental evidence on this point is contradictory. 
Rowland (685), Wells (686), Brenman (687), and Watkins (688) have 
adduced evidence which they believe supports the thesis that antisocial 
acts will be committed by hypnotized subjects. Erickson (689) reports 
contrary results which are in accordance with some of the early ex- 
perimental work of the French school. The positive evidence includes 
having subjects pick up hallucinated snakes, thrusting their hands into a 
cage of snakes (supposedly rattle snakes), attacking with intent to kill 
an enemy Japanese, .stealing money from the experimenter's pocket, 
and throwing acid at the hypnotist who was protected by a glass screen. 
The negative evidence is somewhat comparable, in that the subjects 
refused to carry out similar suggestions. There are certain facts that 
should be mentioned concerning these phenomena. 

The subject in every case knows that the experimenter is responsible 
for whatever happens while he or she is hypnotized. No situation has 
been constructed in which the subject may not feel with certainty that 
drastic harm will not be allowed. If a subject were instructed to stand 
in a street in front of traffic, there is a high probability that the trance 
would be broken. With most women suggestion of immoral acts would 
probably terminate the hypnotic state. Unquestionably certain harm- 
ful and immoral acts would be carried out by hypnotized subjects who 
had no aversion to performing these acts normally. In the writers' 
opinion these situations do not satisfactorily test the hypothesis. The 
occurrence of emotional responses, hallucinations and perversions of the 
reasoning processes should not be questioned. Whether these reactions 
are real or authentic and are occasioned in some manner contrary to 
normal stimulation must be determined by further experimentation. 
Weitzenhofer (690) attempts to reconcile the differences by holding that 
the subject will commit those acts if the situation appears socially 
acceptable to the subject. If the situation appears contrary to his 
ethical system, he will not commit them. 

Following the early observations of Rieger (691) and Charcot (692) 
on the relative fatiguability of the arm muscles in the hypnotic and 
normal states, a series of investigations were undertaken by Nicholson 
(693), Young (694) and Williams (695). Rieger and Charcot felt that 
when the arm was extended and held in position in the hypnotic cata- 
leptic state, it could be maintained in position longer and with 


fewer oscillations than when the arm was held rigidly in the normal 
waking state. Williams has carefully attacked this problem. Smoked 
tracings of arm movements of 8 subjects were obtained by means of a 
string attached to the arm and a stylus writing on a kymograph. The 
results were contrary to those reported earlier by Rieger and Charcot. 
The subjects could not hold their arms up any longer in the trance state 
than in the normal state. There were, however, fewer oscillations of the 
arm during the hypnotic state. 

The problem of work and fatigue is complicated by the nature of the 
instructions given in the normal and trance states and the mere intro- 
duction of the trance itself without any suggestions whatever. Nichol- 
son found an increase in muscular work on the ergograph by hypnotic 
suggestion. This was reflected in the amount of work accomplished and 
a lessening of both subjective and objective fatigue. Even when the 
subject was exhausted in either the normal state or the hypnotic state, 
if changed to the other state no apparent fatigue existed. Young 
found increased ability to grip a dynamometer through hypnotic sug- 
gestion which is in agreement with Hadfield's (696) earlier work. Will- 
iams corroborates partially the findings of these earlier experiments. 
He found an increase in the work done in the trance state as compared 
with the normal state when equivalent suggestions were given in each. 
On the contrary, the trance, per se, did not inhibit the onset of fatigue 
nor did shifting from one state to another obliterate fatigue. 

These apparent differences between fatigue in the hypnotic state and 
normal state can be accounted for only in increased motivation, but our 
knowledge of motivation is so limited that any conclusions are apt to be 
wrong. If the motivation were not artificial or if the penalty were suffi- 
ciently great for inferior effort, there is a high probability that no signif- 
icant differences would be found. Suppose a number of subjects were 
hypnotized and positive suggestions of increased strength were given 
them. If their performances were then checked against their perform- 
ances when one hundred dollars were offered to them to excel their 
hypnotic performance, the outcome, in our opinion, would favor the 
normal condition. We are presupposing that no knowledge of the 
reward existed at the time of the hypnotic performance. Hypnotic 
subjects are motivated to conform to suggestion by the mere fact that 
they serve as subjects and most of them have heard stories concerning 
unusual strength. 

One of the diagnostic tests for deep hypnosis is amnesia. If the 
subject does not remember what occurred during the trance state, he is 


said to have been deeply hypnotized. The spontaneity of amnesia has 
not been investigated although expectancy plays a large role. Amnesia 
can be induced by suggestion so that loss of memory for money or 
jewelry given up during the trance occurs upon awakening. These 
amnesic events can be restored through rehypnotization. This form of 
amnesia is entirely unlike forgetting, since a word from the experimenter 
will re-establish the events in memory. Forgotten material, on the other 
hand, has to be laboriously relearned. The recovery of "so-called" 
dissociated events seems to be favored by the hypnotic technique. 
Emotional factors that inhibit recall can be effectively removed. The 
reality of hypnotic amnesia is open to question since it may be simple 
verbalization in which the subject denies the experience. An experi- 
mental study by Huse (697) on the recall of nonsense material partially 
learned under controlled conditions does not show that the trance is 
superior to the normal state for the recall of such material. Sidis (698) 
has also favored a state more nearly approaching the waking state for 
recall. The reason why hypnosis apparently succeeds in helping to 
recall certain events lies in the fact that the subject's attitude is such, 
that events that would normally cause some embarrassment, are told 
at a time when they are not embarrassing The attention can also be 
directed and restricted to a certain extent so that more ideas related to a 
given topic will arise through the processes of association. In an ex- 
periment by Strickler (699) on learning material similar to nonsense 
syllables, it was found that the learning in the trance period was accel- 
erated when compared with normal learning in the first few trials. The 
later trials are almost identical. Attention in the trance period is 
probably favorable for learning, but in the latter part of the series this 
factor may not be so potent. Bitterman and Marcuse (700) suggested 
amnesia for a list of words during an hypnotic session. After a 48 hour 
lapse of time, during which the subject apparently did not remember the 
words, the words were read again with other words. The subject did not 
recognize the words, according to their report, but autonomic reactivity 

There is another phenomenon that may be mentioned at this point; 
namely, hypnotically induced dreams. There is no reason why dreams 
should not be expected to occur. Whether they are genuine dreams is 
another matter. Subjects may conform to the suggestion by concoct- 
ing stories that are related in the waking state. Since dreams do occur 
normally, we are inclined to accept related dreams as genuine. Klein 
(701) has shown that almost all varieties of dreams can be produced by 


slight sensory stimulation while the subject is in an hypnotic sleep. In 
fact, he has shown that all the dreams in which the analysts revel can be 
produced by such stimulation. Sirna (702) attempted to test the hy- 
pothesis that the hypnotically induced dream is not the same in cortical 
effect as the normal sleeping dream. He obtained encephalographic 
records of the two conditions and found no significant trends in the 
records which would indicate similarity or dissimilarity. 

Post-hypnotic suggestions are suggestions given in the hypnotic 
state which are carried out in the normal state upon a prearranged signal 
or at a set time. The variety of post-hypnotic acts that will be per- 
formed is limited only by the suggestions given. If one is told during 
hypnosis that at 9 o'clock the next day he will go to a store and buy 
perfume, the act will be executed at that time. If the subject is in- 
structed to imitate the song of a bird when the instructor begins lectur- 
ing, at least a crude attempt will be made to carry out the suggestion. 
The explanation usually offered for such performances is that the trance 
is reinstated by the suggested stimulus or else there is a partial carry 
over of the original hypnotic condition. Reinstatement of the trance 
will be produced occasionally by unintentional stimulation. One 
subject used by the writer in some experiments a few years ago was 
hypnotized by counting the number series from one to ten. This same 
subject was working for another man on the problem of crossing out 
numbers; when he ran across the number series from one to ten on his 
work sheet he fell into an hypnotic trance. Post-hypnotic suggestions 
are similar to normal waking suggestions that are carried out at a later 
time. If you suggest to your friend that a particular suit or dress would 
be becoming and the apparel is subsequently purchased, the original 
suggestion may not be remembered, but it has nevertheless been acted 

The hypnotic subject's estimate of time has long been a mystery. 
Many writers claim that hypnotized subjects have unusual ability to 
estimate the lapse of time. Accurate experimental data on this point 
are needed, but this ability like many other abilities probably conforms 
to the normal standards. If the hypnotized subject is told to awaken in 
fifty minutes he will approximate the time. If the hypnotized subject 
is given no suggestion, he will awaken in a period of time. How long 
he will remain in the trance state depends entirely upon the attitude or 
belief that he happens to hold. Some subjects terminate the trance 
almost as soon as the hypnotist leaves; others remain hypnotized for a 
period varying from fifteen minutes to an hour; while still others remain 


in the hypnotic state for several hours or longer. No reports have been 
made of individuals remaining indefinitely in a hypnotic trance without 
definite suggestions to that effect or without suggestions reinforced from 
time to time. An experiment by Dorcus, Brintnall and Case (703) shows 
that in the absence of definite suggestions, most subjects terminate the 
hypnotic state when the experimenter leaves or when they have some 
other important engagement. If the subject passes from a hypnotic 
state into a natural sleep state, habits will be influential in his awaken- 
ing. A discourse on time estimation by normal people is out of place 
here. It is sufficient to say that there are many possible cues, such as 
change in sun position, general movements of people, habits of feeling 
hungry, counting the respiration rate or the heart rate. Much space 
has been devoted to post-hypnotic estimation of time and the duration 
of post-hypnotic suggestions. Many instances of post-hypnotic per- 
formances after a lapse of months and in some instances after a lapse of 
a year have been reported. Bramwell (704), McDougall (705) and 
Hooper (706) report experiments to which the students may refer for 
more specific information. McDougall stresses the point that whatever 
the method the subject uses for keeping track of time, it is done sub- 
consciously. He maintains that they have no thought of the act to be 
performed until almost the exact time of its performance. If one 
wishes to send a birthday greeting to a friend, it is unnecessary to think 
of it constantly from one year to the next. In fact, one frequently does 
not think of it until the day of the birthday. Now if you were asked to 
recall just how you remembered that the birthday fell on that day, the 
associative steps could probably not be recalled. It is therefore not 
surprising that some hypnotized subjects cannot recall the associative 
step involved in remembering that a specific act was to be performed on 
a set date. 


In our preceding discussion, some of the characteristics of hypnosis 
have been considered. It is impossible to construct a theory that will 
account for all the manifold factors that have been mentioned without 
at some point contradicting some of the facts. Practically all theorists 
maintain that an adequate theory must explain the increased suggesti- 
bility in hypnosis, amnesia, loss of volition and rapport. The validity 
of these criteria needs to be examined. 

Hull and Huse, (707) in a study of the suggestibility in the normal 
and waking states, found in securing the falling reaction that 1\ times as 


much time was required for the waking suggestion to be effective as was 
required for the trance suggestion. Habituation to suggestion was also 
clearly demonstrated. The mean suggestion time for 8 subjects on 
the fourth experimental session was approximately half that for the 
first session. Quantitatively, increased suggestibility may be a valid 
criterion. On the contrary, the phenomena "produced in the waking 
state are as varied and complex as the phenomena produced in the trance 
state. Wells, Forel, and Moll have induced almost the entire gamut in 
subjects never hypnotized. 

Amnesia, which may be related to absent-mindedness, is not a valid 
criterion of hypnosis, since the amnesia is more apparent than real. 
Strickler's work on the post-hypnotic amnesia for nonsense material 
seems to confirm the notion that amnesia is more prevalent in the 
trance state than in the normal state. However, his findings are 
vitiated by the fact that he selected subjects in whom amnesia was the 
outstanding characteristic. It is not surprising that they would have 
difficulty in recalling and in relearning nonsense material learned under 
hypnosis since their set favored the condition. 

Loss of volition is genuine only to a certain extent. Thinking, 
involved in carrying out many suggested acts and the avoidance of 
objects in the environment, must be taken as negative evidence. 

Is rapport the one essential feature of hypnosis? Rapport may be 
defined as the state of dependence of the subject upon the hypnotist. 
Young (708) corroborated the contention of Braid and Moll that the 
condition is really an artifact of suggestion. Subjects, by prior auto- 
suggestion, exhibit whatever degree of rapport they decide upon. They 
may be in rapport for only a limited number of suggestions or a wide 
variety of suggestions. The cataleptic state in animals resembles 
closely the cataleptic state in humans; yet no writer has seriously con- 
tended that a state of rapport exists in animals. 

Some years ago, phenomena were reported that seemed to differenti- 
ate hypnotized subjects from normal subjects. The reports indicated 
that the alpha brain waves were present when a suggestion of blind- 
ness was given even when the eye was stimulated by light. The waves 
were suppressed when the suggested blindness was removed. These 
supposed facts tended to support the notion of an altered visual pattern. 
More recently work by Lundholm and Lowenbach (709) proves that 
the original investigators erred. Dynes (710) and Ford and Yeager 
(711) have demonstrated rather conclusively that the electroence- 
phalograms of hypnotic subjects in the absence of positive emotional 


suggestions do not differ from those in the waking state. Dynes found 
that the sleep records did not conform to either the waking or hypnotic 

It is obvious that the so-called criteria of hypnosis are not necessarily 
valid criteria and hence any theory founded on such bases is invalid. 


One of the areas that has been explored in recent years particularly for 
psychotherapeutic purposes is regression under hypnosis. This is the 
attempt to reestablish earlier levels of activity under direct suggestion. 
The data are equivocal. Young (712) tried to reestablish the 3 year 
age level of hypnotic subjects and tested their ability on a standard in- 
telligence test. Their performance on the average was that of the 6 
year old child. Unhypnotizable control subjects when attempting to 
simulate the 3 year level gave approximately a similar mental age. 
These findings may indicate that this is the earliest age level that can be 
recalled readily by the subjects. Sarbin (713) gave the Stanford Binet 
to subjects regressed to the 8 or 9 year level and later administered the 
same test to the same subjects simulating similar age levels. The results 
were not clear cut but he felt there was some relation between the depth 
of hypnosis and the success of regression. Gidro-Frank and Bowers- 
buch (714) attempted to control the plantar reflex through hypnotic 
regression. This reflex is present only in the early months following 
birth. They claim that 3 of these subjects showed the reflex when re- 
gressed to the 5th month level but 2 others did not. Studies of hand- 
writing and drawing under hypnotic regression have been carried out. 
There is evidence of a change toward infantile types of drawing and 
childish writing, but these need to be compared with samples of writing 
of the same subjects at early age levels. A report has come to the 
writer of a change in the brain wave pattern of an epileptic whose 
seizures began later in life. According to the report, when regression 
took place, the brain wave pattern was that of a normal subject. Much 
experimental work needs to be done in this area before proper evaluation 
of the technique can be made. 


Theories founded upon neural exhaustion by monotonous stimuli, 
the function of the synapses, circulation changes, sleep-like states, 
analogies to hysteria, dissociation, and restriction of volition, fail in the 
main to satisfy numerous points that can be raised. A brief summary 


of each of these theories is presented in the following section. Bennett 
(715) has propounded the theory that hypnosis is a result of fatigue of 
certain parts of the cerebral lobes through monotonous stimulation with 
consequent overactivity of the nonfatigued parts. The theory can have 
little value in light of our knowledge of the unitary functioning of the 
cortex. The ease and rapidity with which the hypnotic state can be 
induced and abolished also argues against the acceptance of the idea. 

The circulatory theories have arisen from the supposition that hyp- 
nosis is a modified form of sleep, and therefore the same criticisms may 
be made of this theory that were made against accepting hyperemia or 
anemia as causes of sleep. The fact that drugs seem to aid the estab- 
lishing of the hypnotic trance has been used as an argument in this 
connection, but this influence of drugs is primarily due to suggestion 
rather than the modification of circulation. Bernheim, Forel, and 
Bechterev have held that hypnosis is a modified form of sleep since 
stimulation similar to that which produces dreams results in partially 
integrated activity. The theory had its inception in the observation of 
phenomena common to both states. Factors, such as monotonous 
stimulation, relaxation, and expectancy, tend to produce both sleep and 
hypnosis. Hypnotic sleep is similar to normal sleep. Opposed to the 
identity or similarity of sleep and hypnosis are such factors as differences 
in respiration, pulse rate, and blood pressure in the two states. Studies 
by Wible and Jenness (716, 717) and by Bass (718) show that sleep and 
hypnosis are dissimilar states. Electrocardiograms and pneumographic 
records obtained by the former investigators show that the records more 
closely resemble the records of the waking state than the hypnotic state. 
The latter investigator found that the patellar reflex and the response to 
a buzzer are diminished in sleep, while in hypnosis they are practically 
the same as in the waking state. Catalepsy which is one of the phe- 
nomena of hypnosis is not prevalent in sleep. Stimulation in sleep 
results in awakening or at best very poorly integrated activity whereas 
stimulation in hypnosis does not terminate the trance unless specific 
suggestions are given to that effect. Since the theories of sleep are 
inadequate, it follows that any theory of hypnosis constructed on a 
similar basis would be inadequate. 

Charcot's (719) theory, which in the main is subscribed to by Janet, 
assumes that hypnosis is an artifically induced neurosis. It is closely 
allied to hysteria, and only those people who have a definite neurotic 
tendency are susceptible to hypnosis. In hypnosis, as well as in hysteria, 
there occurs a permanent or temporary diminution of psychic energy 


which produces a breakdown in the synthetizing forces of consciousness. 
This restriction of consciousness gave rise to the concept of a narrowed 
field of consciousness, which goes along with hysteria according to Janet. 
If these conditions are artificially produced through monotonous stimula- 
tion and direction of attention, hypnosis is the resultant state. Narrow- 
ing of consciousness, however, is only descriptive of the actual state and 
affords no explanation for the actual mechanisms involved. 

The dissociation theory held by Coriat, Prince and others has already 
been elaborated in Chap. VI under the discussion of dissociation and 
need not be restated here. 

In general, the facts derived from physiology and neurology seem to 
offer very little direct evidence for explaining hypnosis in these terms. 
One of Bernheim's (720) ideas is the most tenable. He holds that 
hypnosis is suggestion, and no marked difference exists between normal 
acts carried out as a result of suggestion and supposedly hypnotically 
induced acts. Actions on the part of the hypnotized subject are not 
involuntary, unconscious, or dissociated. Volitional control in the 
popular sense still exists, otherwise the many complex phenomena would 
never occur. Voluntary action according to Dunlap (721) "is either 
merely action in which the idea of the act itself (or of its result) is es- 
sentially involved, or it is a series of acts in which the idea of the final 
act is involved in the first one. This definition includes James* ideo- 
motor action and properly so." When the suggestion is given for clos- 
ing the eyes, the subject acts voluntarily or, stating it another way, the 
idea is the action itself. In some complex phenomena, the idea of the 
first act is involved in the final one. The subject may reply, if ques- 
tioned, that he could not resist closing his eyes. This simply means 
that no intervening idea occurred which involved contrary action. If 
the subject is questioned as to why no contrary ideas occurred, a satis- 
factory answer cannot be given, except that he was trying to follow 
instructions or cooperate. This is again evidence of voluntary action. 
Why are some people good subjects and others poor ones? The answer 
is that systematization of ideas concerning the sequence of acts has 
already been established through reading, thinking or demonstration. 
The acts of the hypnotized individual are appropriate for his ideational 
sequences. The only reason that the observer or audience considers 
them inappropriate is because the same series of ideas does not occur 
to him or to them. This would account for the fact that children more 
readily act upon suggestion than adults. The knowledge of the appro- 
priateness of the act is limited. The mere fact that one acts with limited 


knowledge or without inhibitory ideas does not make his acts any the 
less voluntary. Most subjects tacitly agree to carry out suggestions 
when they submit to hypnotic experimentation, and those subjects 
that are apparently hypnotized against their "will'* have undergone a 
radical change in their sequence of ideas. You may maintain that 
people do things under the influence of hypnosis that they would not 
normally do. We have attempted to show that all forms of activity 
that can be produced under hypnosis can also be produced in the waking 
subject under appropriate ideational circumstances. Many people 
play the clown at times and they appear foolish, but certainly their 
acts are not involuntary. It seems to the writer that the phenomena 
of hypnosis can be explained in terms of the subject's voluntary accept- 
ance of ideas suggested to him and in terms of his attitudes and beliefs 
in regard to hypnosis. No experiments have shown successfully that 
totally inappropriate acts have been carried out by hypnotized subjects. 
It does not follow that the hypnotized subject is simulating response. 
On the contrary, he is voluntarily carrying out the act to the best of his 
ability. The phenomena of auto-suggestion favor voluntary action 
rather than involuntary action. Cases of conversion hysteria indicate 
that actions which are appropriate to the ideas of the subject occur and 
are volitional, although they are inappropriate according to the observer. 

If modifications of processes not under voluntary control occur, then 
some revision of the notions set forth above will have to be made. Our 
knowledge of voluntary control of so-called involuntary processes is 
so limited for the waking state that no clear-cut statements can be made. 

Welch (722) (723) has recently reemphasized the conditioning theory 
of hypnosis. He explains the hypnotic state in the following manner: 5 

"Having prepared his subject, the hypnotist performs his first act of 'hokus-pokus' and 
initiates the first step in the process of conditioning. He asks his subject to stare at a 
light or small bright object, usually held in a position which will cause a slight eye strain. 
Staring at this object will naturally tire the subject's eyes, make him blink, and eventually 
give him the desire to rest his eyes by closing them. The hypnotist capitalizes on the 
effects of these purely physiological factors. He first tells the subject that his eyes feel 
tired, very tired, very tired indeed, and of course they do feel tired from staring at the 
bright object. Note, however, that just as salivation in the Pavlovian situation, brought 
about by the presence of food, became associated with the sound of the bell, so the feeling 
of tiredness in the hypnotic situation, brought about by staring at a light, became associ- 
ated with the words of the hypnotist, 'Your eyes are tired.' Without such as association 

5 Welch, L, Reprinted by permission from Journal Abnormal and Social Psychol., 
I947> 42, 3 60 - 


there would be no more cause for the subject's eyes to feel tired than for Pavlov's dog to 
salivate when a bell was sounded under ordinary conditions. 

Next, the hypnotist may tell his subject that his eyes will blink but because of the eye 
strain they blink anyhow. A second time the hypnotist's words have become associated 
with what he has described. When the subject was told that his eyes were tired they felt 
tired, when told that they would blink they actually blinked, and now, when told that he 
feels like closing his eyes, because of the eye strain there is a tendency for him to close 
them. Thus, the hypnotist has so far brought about three successful stages in the process 
of conditioning. 

All of the hypnotist's instructions from the very beginning have been given in a soft, 
monotonous tone of voice. Any monotony in a sense modality is conducive to a soporific 
state and hypo-associative activity. This is a psychological fact. Anyone with sufficient 
power of concentration can put himself into a drowsy state if he merely attends to some 
soft monotonous series of sounds. Once more the hypnotist captitalizes on a physiological 
effect. He tells the subject that he is completely relaxed, he is sleepy, very sleepy, he is 
sinking down into a deep sleep, etc. He may even stroke the subject's forehead very 
lightly and rhythmically with the back of his finger. Hence, the hypnotist is able to 
associate the instruction to 'sleep' with the soporific effects both of his voice and of the 
tactual stimulus produced by his finger stroking the subject's forehead." 

There is much to be said for this point of view. However, the postu- 
lations of conditioning for hypnosis would have to go back over a much 
longer period of time to explain those cases who become deeply hyp- 
notized by the hypnotist simply pointing a ringer at them. In these 
cases, there is no long preparatory period except the ideas that the 
subject held previously. This would involve very complex forms of 

White (724) has stated in somewhat different language, the general 
hypothesis to which we subscribe, and it is repeated at this point since 
it may enable the student to obtain a firmer grasp of the theory. 

"As a first step it is proposed that hypnotic behavior be regarded as a meaningful, goal- 
directed striving, its most general goal being to behave like a hypnotized parson as this is 
continuously defined by the operator and understood by the subject. Such a view replaces 
the older notions of automatism and dissociation which have persisted in a peculiarly rigid 
and unenlightened form to the great detriment of hypnotic theory. Reasons for pre- 
ferring the hypothesis of goal-directed striving are found by a direct inspection of typical 
hypnotic phenomena. The application of the hypothesis puts several of these phe- 
nomena in a quite new light, particularly the post-hypnotic behavior which has played such 
a prominent part in experimental studies. The subject, it is held, is ruled by a wish to 
behave like a hypnotized person, his regnant motive is submission to the operator's de- 
mands, he understands at all times what the operator intends, and his behavior is a 
striving to put these intentions into execution." 




In the following sections we shall examine, classify and describe some 
of the more important disorders, the psychoses and the psychoneuroses. 
The discussion of these disorders is sometimes carried on as if they were 
entirely removed from and unrelated to normal psychological reactions, 
an error which has induced much misconception. Consequently, before 
we turn to an examination of these phenomena, it will be well to consider 
basic facts. 

The difficulty of drawing a dividing line between the normal and 
abnormal has already been mentioned. It should now be obvious to 
the student that no individual exists who may be said to be perfectly 
normal in all traits. Just as one deviates from the average or normal 
in certain physical traits such as height or weight, so one also deviates 
from the normal in mental traits or reaction patterns. It is only the 
more serious deviations which render the individual incapable of adjust- 
ment to his environment that are viewed as abnormalities. 

The appreciation of the behavior of the patient comes only through a 
thorough analysis of the entire life of the individual. The evaluation 
of the part played by both organic and functional factors can be obtained 
only from a careful study of what the individual was to begin with and 
how he has changed as a result of his life experiences. Since we view 
the individual as a psychobiologically integrated organism, the under- 
standing of the behavior of this organism must be a result of an analysis 
of all factors, genetic and environmental. 

There is still a widespread popular belief in the extent and potency of 
innate tendencies. Especially there is a tendency in the popular mind 
to consider social and individual maladjustments as manifestations of 
some inborn perversity of human nature. The more complicated and 
difficult a problem is, the greater is the tendency to explain it on the 
basis of some easy and mysterious force. One of the easiest of such 
methods is the instinct theory. It is not necessary for us at this time 
to go into a detailed discussion of the various classifications of the 
alleged instincts. It is sufficient to note the diversity of opinion and 
lack of agreement. 



One of the earliest of these classifications asserted that there were two 
fundamental instincts, self-preservation and race preservation, while 
Bernard (725), in a survey of the writings of several hundred authors, 
reports that 14,046 human activities had been termed instinctive by 
someone. McDougall's (726) list, which was probably the most influ- 
ential, specified 7 major instincts, the number later being expanded to 
14; and Carr (727), examining several standard textbooks, found 38 
instincts mentioned, 16 of which were cited by a majority of the writers. 
It must be obvious that a term so widely and loosely used can be of 
little value to scientific psychology. 

The use of the term popularly is even more complicated, so much so, 
in fact, that it is now frequently used when the exact opposite is meant 
to be implied. For an example, one frequently hears a person say that 
he "instinctively" did this or "instinctively" did that when he means 
to indicate that his behavior in a certain situation has been so well 
learned by repetition that it appears to be practically automatic. 

In view of the recent demonstrations of the fact that many of the 
so-called instincts do not exist and that many so-called instincts are 
really learned, the older instinct theories have lost their value for the 
explanation of behavior. For an example, the so-called hunting instinct 
can be shown to be nothing more than a positive reaction toward many 
things and a tendency to manipulation. The maternal instinct, a very 
popular one among adherents of the instinct school, does not hold up 
under careful scrutiny. Certainly many of the mothers of illegitimate 
and unwanted children show no such tendency, and the assertion that 
motherhood gives instinctive skill in the handling of the child is pure and 
simple fiction. Anyone who has had the opportunity to observe care- 
fully must have been aware of the new mother's clumsiness in the care 
of the new-born and must have seen that skilful maternal care develops 
through learning and experience. The so-called gregarious instinct, or 
the tendency to be better satisfied when in the company of others than 
when alone, is another obvious tendency to give the name instinct to 
a behavior pattern which is the result of learning. In the beginning, 
the child is helpless and must depend upon others for the satisfaction of 
its needs. Thus his satisfactions are obtained when others are present, 
and he may be expected to learn to desire the company of others in 
order that his satisfactions may be greater. It may be argued that the 
individual also experiences many dissatisfactions in the company of 
others; and consequently, if gregariousness is not an instinct, it should 
disappear. As a matter of fact, this is precisely what happens. If the 


dissatisfaction in group situations greatly outweighs the satisfactions, 
the individual tends to withdraw from the group and exhibits a desire 
to be alone. .,. 

Even the supposedly fundamental instinct of self-preservation will 
bear careful examination. It would appear that the individual does 
not desire merely to preserve himself, but he desires to live in order that 
he may satisfy other desires. On the whole, the instinct theory was a 
confession of ignorance. Any activity that could not be explained was 
assumed to have come about just by the nature of things and was called 
an instinct. 

Another group of psychologists, influenced primarily by the behavior- 
ists, attempted to explain behavior mainly in terms of reflexes. For 
these investigators it was merely necessary to determine what acts 
appear at birth and to consider that these are the native responses. The 
term reflex is, however, merely a convenient abstraction describing the 
simplest possible neural circuit. Actually no such simple circuit ever 
operates in isolation. A response may take place in a relatively circum- 
scribed muscular or glandular organ as a result of a relatively specific 
stimulus, and it is this kind of response that is now being called reflex 
by most psychologists. 

It may be possible to refer to some of the more complex learned acts 
as chains of reflexes, but complex behavior more likely develops from 
the diffuse, less specific mass reactions which are in evidence at birth. 
This diffuse, non-specific activity of the infant, in which the body acts 
as a whole, is probably to be explained as being due to the unorganized 
condition of the nervous system of the new-born. Any stimulus tends 
to spread its effect over a number of pathways and results in the activity 
of many effectors. 

At this point it may be well to observe that the appearance of 
responses at birth is not necessarily evidence that such responses are 
native and that they have not already been modified by learning. The 
infant does not spring from nothingness to emerge at birth into complete 
functional existence. The structure of the nervous system and the 
behavior of the organism develop gradually during the prenatal period. 
The embryological studies of development may yet teach us much about 
the origin of traits, particularly with regard to the role of stimulation 
and of environmental factors before birth. Indeed, most of the specific 
activity present at birth has been prenatally learned, and that behavior 
appears initially as a mass reaction of the entire organism. 

Coghill's (728) study on the larval Amblystoma, a tadpole stage of a 


variety of salamander, is most illuminating in view of the fact that this 
amphibian begins life in a transparent egg and can be easily observed 
from fertilization to maturity. As a result of his experiments, Coghill 
says, "Behavior develops from the beginning through the progressive 
expansion of a perfectly integrated total pattern and the individuation 
within it of partial patterns which acquire various degrees of discrete- 
ness." He was also able to show that the course of individuation is 
from head to tail and from central to peripheral. Experiments with 
human and other mammalian fetuses tend to agree with the results 
obtained by Coghill in his study of the Amblystoma. Thus embryo- 
logical experimentation indicates that behavior appears initially as mass 
reaction of the entire organism, individuation developing later. At 
birth, however, the organism displays, along with the mass activity, a 
number of specific reflexes; and some psychologists have attempted to 
explain how these may have been learned before birth. For an example, 
in the mass activity of the fetus, the contraction of the hand and arm 
muscles involved in grasping may occur first as a part of the total 
activity pattern. When this occurs, the pressure receptors of the 
palmer surface of the hand will be stimulated by the pressure of the 
fingers against them, sending a sensory impulse to the central nervous 
system. In this way two reactions involving adjacent neural tracts, 
the sensory and the motor, are simultaneously active. The pressure on 
the palm, acting at the same time as the motor response, will become 
connected to it and thereafter elicits the specific response, the grasping 
reflex. For more complete discussion of this topic reference may be 
made to Holt's (729) work. 

In any event, the balance of evidence seems to point to the fact that 
in the beginning the organism responds as a whole, any kind of stimula- 
tion eliciting diffuse movements rather than specific ones. The begin- 
ning of the learning process may, therefore, be assumed to be this pattern 
of mass activity. Learning, then, is not the addition of reactions, but 
the refinement of the total pattern and the development within it of 
partial patterns of various degrees of independence. In early infancy, 
as a part of mass reaction, progressive movements of the legs similar 
to those later used in walking may be noticed. The actual walking 
must wait, not only for growth and the general strengthening of the 
body, but for the separation of specific coordinated movements from 
the pattern of mass activity. Our failure to recognize that learning 
progresses in such a fashion is probably somewhat due to the fact that 
much of the experimental work in this field has been carried on by 



examining isolated and specialized portions of the complex whole. For 
an example, the effect of reactions occurring together has been investi- 
gated by experiments in which attention has been directed towards 
only a relatively simple part of the total stimulus pattern and a very 
specific part of the total response. Such experiments may be best 
understood by referring to the work of Pavlov (730) whose investiga- 
tions were carried out under rigorously controlled conditions. Pavlov's 
studies showed that if a drop of weak acid was placed on the tongue of 
a dog, he would respond with an increased flow of saliva. The acid 
could then be said to be adequate stimulus for the salivary response. 
The sound of the bell, which is not connected with the salivary response, 
would not cause the dog to salivate but would result in the hearing 
response, which includes, among other things, the pricking up of the 
ears. If, however, the dog was put through a training period during 
which time the bell was always sounded when the acid was dropped on 
the tongue, eventually the sound of the bell alone would be sufficient 
to cause a marked salivary response. This process has been referred to 
as the conditioning of responses. 

Watson (731) has shown in his work with infants how the emotional 
life of an individual becomes much more complicated through associa- 
tion and the conditioning of responses. The child evidences a fear 
response to a loud noise, but shows no fear at the appearance of furry 
animals. If, however, the loud noise is always sounded when the furry 
animal is presented to the child, the fear response will eventually occur 
when the furry animal is presented alone. The child has been condi- 
tioned to a fear of the animal because the animal has become associated 
in its experience with a loud noise by which it was originally frightened. 
We may now carry this farther and condition the child to fear his rattle, 
by presenting it always at the same time with the furry animal which 
the child has learned to fear. The complex emotional life of the indi- 
vidual is built up in this way by the transfer of feeling from one thing 
to another through association. The tracing of the origins of these fears 
in the infant is a relatively simple matter because of the limited number 
of experiences that the new-born has had; but in the adult, or even the 
older child, it is a more difficult problem. 

A case may make the situation a bit clearer. A young woman, an 
excellent airplane pilot, who was considered by her classmates to be 
especially fearless, asked the biology professor to excuse her from the 
day's work because she was dreadfully afraid of worms. She reported 
that she knew, of course, that the worms were not dangerous, but that 


it was impossible for her to get near them. She could not remember 
ever having been frightened by them, but some careful tracing of asso- 
ciations led to the following disclosure. As a small child she had had 
two rather unusual and terrifying experiences; and on each occasion 
she had been playing with a couple of small worms. It is important to 
recognize that every experience is a complex experience, composed of 
many elements; and any one of these elements may evoke the total 
response at a later date. Unfortunately the original situation which 
produced the fear is frequently not remembered by the subject, and 
consequently it appears to be a fear with no explicable basis. 

That the conditioned reaction does not depend on conscious processes 
or on any act of deliberation is well indicated by the work of Cason (732) 
on the conditioning of the pupilary reflex. Cason's experiment also 
shows how by training, the same stimulus may produce diametrically 
opposite reactions in different persons. An increase in the light falling 
on the retina causes a contraction of the pupil; a decrease causes a dila- 
tion. These activities are almost totally independent of voluntary 
control. The sound of a bell, on the other hand, has no appreciable 
original effect on the pupil of the eye, but causes an attitude of atten- 
tiveness. Cason, with one group of subjects, sounded a bell simulta- 
neously with the increase of light intensity, and with another group 
sounded a bell simultaneously with a reduction of light intensity. In 
both groups, after about 400 repetitions, Cason secured condition- 
ing so that the sound of the bell alone would stimulate a change 
in the size of the pupil. Such an experiment clearly shows the possi- 
bility of producing in two groups of individuals diametrically opposed 
reactions to the same stimulus which in the beginning was powerless to 
produce either reaction. Such conditioning processes are constantly 
going on throughout life. The understanding of such principles makes 
it unnecessary for us to use mystical explanations for the fact that two 
individuals have diametrically opposite feelings toward the same object. 
Figure 32 will illustrate what took place in Cason's experiment. 

It should also be noted that the conditioned reactions are not only 
independent of volition, but that even the fact that the reaction has 
occurred may be unknown to the subject. Thus, the girl who feared 
the worm need not remember the experience by which she was condi- 
tioned. In many patients fears that appear absurd and ridiculous 
are, in reality, conditioned reactions that persist even though there is no 
memory of the conditioning episode. 

In a large percentage of the responses made by the organism, however, 



a period of time elapses between the stimulus and the response so that 
the reaction may be said to be delayed. During this time there may 
be active restraint or inhibition of the response. In such instances 
some purely extraneous stimulus may release the inhibition, and the 
complete response may appear. One of the authors saw a young 
married woman who had had a quarrel with her husband and was emo- 
tionally upset by the situation. She appeared in her office, however, 
outwardly calm and showing no signs of strain. When she attempted 


Bright light Contraction of pupil 

(unlearned stimulus) 

Dim light * Dilation of pupil 

(unlearned stimulus) 


First group 

Bright light + Sound of bell Contraction of pupil 

(unlearned stimulus) (indifferent stimulus) 

Second group 

Dim light + Sound of bell Dilation of pupil 

(unlearned stimulus) (indifferent stimulus) 

First group 

Sound of bell > Contraction ot pupil 

(substituted stimulus) 

Second group 

Sound of bell - Dilation of pupil 

(substituted stimulus) 

FIG. 32. Sketch showing the conditioning of diametrically opposed reactions to a 
stimulus which in the beginning was not connected with either reaction. 

to use her typewriter, a lever became jammed, and she burst out in a 
torrent of tears and could not be calmed for a considerable period of 
time. r%9 r g an J 7 ?d rnnHnrf may rhfn frequently be seen as a failure 
.of inhibition., 

The ability to understand both normal and abnormal behavior is not 
gained, however, if we examine only how a man behaves and make no 
attempt to understand why he behaves. The facts underlying motiva- 
tion have been presented in the chapter on Desires, Feelings, and Em.q- 


tions. It should now be clear that the instinct theory fails to explain 
motivation; nothing is gained by saying that the boy fights because of 
an "instinct of pugnacity." This is simply saying that one fights 
because he has a tendency to fight. The concept of motivation may be 
greatly clarified by a consideration of tensions. It has previously been 
pointed out that in the motive of hunger, the stimuli which arouse ac- 
tivity are the sensory reports of stomach contractions. Thus the inner 
physiological state is a stimulus that arouses activity. In many other 
conditions visceral tensions acting upon receptors can be seen as operat- 
ing stimuli. It should also be noted that a loud noise (or any other 
overstimulation) is adequate stimulus not only for a muscular response, 
but also for a series of visceral changes which may persist after the noise 
stimulus has ceased. The loud noise may then be seen as setting up an 
inner physiological state or emotional tension which is a stimulus to 
activity. The first responses to such stimuli are not, however, specific 
in type, but are rather diffuse activities of the organism as a whole. 
From this point it is not difficult to see how other stimuli as a result of 
conditioning may become adequate for particular responses. The appet 
for the desire to quench one's thirst may be the dryness of the mucous 
membrane of the upper portion of the alimentary tract, but external 
stimuli such as the sight, odor, or mention of a drink that has been satis- 
fying becomes an adequate stimulus for thirst. We should also note 
that this learning not only serves to extend the range of stimuli that will 
arouse the desire, but also tends to modify the activity that results. 
Thus the primary sources of activity are viewed as stimuli, especially 
internal stimuli in the form of visceral tensions. The field of motivation 
becomes complicated by the fact that many forms of learned behavior 
also function as desires even though they do so through the operation 
of the fundamental physiological states and tensions. 

The ability to understand the behavior of the so-called abnormals, 
much of which may appear to be mysteriously acquired, is best gained 
by an examination of normal processes of adjustment. The strivings 
of organisms are not all open to immediate satisfaction. The animal 
does not always find food available when hunger pangs assail; the human 
is not always able to gain social approval, though the demand for it 
may be great. Many obstacles will appear which will thwart or delay 
the satisfaction of desires. The tensions which develop will stimulate 
the individual to many forms of reaction in attempts to gain satisfaction 
through the reduction of the tensions. The results of numerous experi- 
ments show that adjustment to undesirable conditions is not typically 


human, but is found in some of the lowest animals. Jennings (733), 
for an example, describes the behavior of the stentor in response to 
experimentally induced annoyance and shows how this simple animal 
exhibits a repertoire of four adjustment reactions which it makes, one 
after another, until readjustment is effected. Ultimate satisfaction in 
adjustment depends in a large measure upon the ability of an individual 
to continue varying his responses until the tension is sufficiently relieved. 
In many instances satisfactory adjustment is difficult to obtain because 
of excessive persistence in an unadaptive mode of activity. Persistent 
non-adjustive reactions continue because of the inability of the indi- 
vidual to vary sufficiently the mode of response and because of the dis- 
organized character of the emotional response. This is clearly seen in 
the worrier who makes the same useless responses again and again in 
spite of the fact that these responses do not lead to satisfactory ad- 

Satisfactory adjustments are those which appreciably reduce the ten- 
sion, and responses will, of course, vary considerably in their effective- 
ness. The unattractive girl develops tension as a result of her inability 
to attract men, and obviously this tension will be most satisfactorily 
reduced by actual success in attracting men. In general the most direct 
tension-reducing reactions are the most effective and satisfying; but 
when these are impossible or difficult to attain, substitute solutions of 
various types will be attempted. Thus the unattractive girl may use 
such substitute adjustments as withdrawing from competition, becoming 
a man-hater, competing with men in their own occupational fields, 
turning her entire attention to intellectual pursuits, or becoming emo- 
tionally attracted to members of her own sex. Such substitute solutions 
will vary in their effectiveness as tension reducers. It is a simple matter 
to note that some adjustments are better than others, but we must not 
fall into the error of assuming that any tension situation can be viewed 
without relation to other needs and wants. For an example, the most 
direct satisfaction of the mastery motive would be to fight and overcome 
one's rivals. Even if this could be attained, however, it might not be 
a superior form of adjustment, since it might severely thwart the 
achievement of other ends. The individual who attempts to reduce 
tensions resulting from one situation in such a fashion that other desires 
are thwarted may find that tensions are increased rather than decreased. 
Satisfactory adjustment demands integrated behavior of individuals to 
the total situation. 

In our discussions of the psychoses and the psychoneuroses it will fre- 


quently be necessary to speak of regressions, compensations, rationaliza- 
tions, projections, and a host of other reactions which are not to be 
construed as abnormal except in respect to the degree in which they are 
manifested, and the conditions under which they occur. 

An examination of their use by normal individuals will help us to 
understand the greater use that is made of them by abnormal people. 
The simplest human reactions in the face of frustration are either to 
increase the vigor of direct attack or to withdraw from the threat with 
fear and anxiety. 

The development of direct aggression and the use of the temper 
tantrum are understandable in the young child who is being frustrated, 
threatened, and punished while he is still unable to grasp the reason 
why or to communicate adequately concerning his problem. Some use 
of aggression, even ineffectual direct aggression, will continue to be 
evidenced in the lives of all people, but in a number of individuals the 
use of direct aggression will become exaggerated and habitual and will 
constitute a serious personal maladjustment. 

In much the same way we may expect to find that all young chidren 
will react to some threats by the adjustive technique of withdrawing. 
There is even a likelihood that this response will appear with greater 
regularity than aggression since in many situations it is more acceptable 
to others as well as more appropriate. Most of the early withdrawals 
are non-specific and inadequate, and consequently they become in- 
timately associated with fear and anxiety. What complicates the prob- 
lem is the fact that as the individual grows older, the direct external 
threats that are more easily understood are supplemented by personal 
attitudes. The roles once played by parent, teacher, pastor and police- 
man are now embodied in rules of conduct, opinion of others, and one's 
own conscience. The task of fleeing from one's conscience or opinion is 
infinitely more complex than the childhood flight from the parental 

These techniques of direct aggression and simple withdrawal are 
gradually elaborated into innumerable complex reactions. Each in- 
dividual continues to use a variety of combinations and intensities of 
these adjustive techniques, and it is not unusual to find withdrawal used 
as an aggressive technique, or aggression used in order to make with- 
drawal possible. Thus the person who has learned to prefer seclusion 
may employ direct aggression in order to secure his asocial privacy; or 
simple withdrawal may be used to bring about the vengeful destruction 
of another's plans. 


The selection of one or another of these special adjustive techniques 
as an habitually preferred procedure will depend upon the same factors 
operative in other learnings. The assigning of names to the various 
types of adjustments is extremely difficult, but there is a practical 
necessity of presenting some classification. The types of adjustment 
most frequently described appear to stem from the fundamental ag- 
gression and withdrawal adjustments and are therefore frequently re- 
ferred to as adjustments of defense and escape. Thus attention getting, 
identification, compensation, rationalization and projection may repre- 
sent defensive techniques which are more or less aggressively directed to- 
ward the difficulty or its origin, while seclusiveness or insulation, nega- 
tivism, regression, repression, and fantasy may represent escape tech- 
niques characterized by withdrawal and attempts to retreat from the 
problem. There is, however, much overlapping and they should not be 
interpreted as being fundamentally distinct types of adjustment. 

Attention getting. One of the simplest and earliest adjustive tech- 
niques to make its appearance is that of attention getting. Crying, which 
is at first merely a part of the infant's vigorous activity, nevertheless 
tends to bring attention. It is not surprising, therefore, that through 
the ordinary learning processes, crying may become more or less habitual 
as an attention getting device resulting indirectly in the reduction of the 
tensions of need or anxiety. Breath holding, temper tantrums, thumb 
sucking, refusal of food, bed wetting and a variety of other activities 
develop as attention getting devices. As the child grows older, the scope 
of devices widens to include showing off, teasing, fighting, obscene 
behavior or language, deliberate disobedience, and various other activi- 
ties. All of these activities will be found in normal behavior, and such 
attention getting devices cannot be considered abnormal unless they 
become excessive or are inappropriately used. Both the overprotected 
or overindulged and those who have been neglected may develop un- 
satisfied needs that may result in abnormal use of attention getting ad- 

It is essential to note the subtlety of the operation of this adjustment 
as well as that of all of the other adjustments to be considered. Such 
adjustments may be effectively used without having been planned, 
recognized or understood by the person using them. In fact, it is the 
subtlety of the devices that makes them so effective as tension reducers. 

The abnormal use of the attention getting device may be particularly 
noticeable in the behavior of hypochondriacal, hysterical and certain 
manic patients. 


Identification. Tension reduction may be accomplished by identifying 
one's self with others whose achievement or standing is great. The 
child begins his life under circumstances which made identification in- 
evitable. He starts life as a member of a family, and others identify 
him as being a member of this group. The growth of the identification 
may be noted by watching the child change from such statements as "I 
can do this, watch me do that", to statements calling attention to the 
father, the gang, team, church, etc. His personal status can be en- 
hanced by identifying himself with an important individual or a going 
group or organization. Thus he may develop habitual attitudes of self- 
esteem and security on the basis of his identification. In many instances, 
the identification becomes so important to his security that any attack 
upon the identified person or organization will seem to threaten that 
security. It is not surprising, therefore, to find a disproportionate 
emotional violence displayed in defense of the individuals or organi- 
zations with which the identification has been established. 

Identification is a normal form of adjustment often deeply ingrained 
by the trial and error processes of adjustive learning and likely to be 
exaggerated by those who have excessive feelings of inferiority. In 
those who are mentally ill it is seen most clearly in delusions through 
which the patient magnifies or sanctifies himself. The paranoid patient 
evidences a strong belief in his identifications and arrogantly defends 
them at all cost, whereas the manic patient usually does not seem really 
to believe the identification. 

Compensation. The tensions and anxieties accompanying real or 
imagined defects may be compensated for by substitution of and over- 
emphasis on some other need satisfaction sequence. The compensatory 
habits may give satisfaction because they are close substitutes for real 
achievement and may serve to divert attention from real or imagined 
inferiority. Compensatory behavior as a means of reducing anxiety is 
plainly evident in all normal behavior. The small man who gets his 
feeling of mastery by a loud voice or authoritative manner, the mother 
who turns to her children when her husband's neglect brings anxiety, the 
unsuccessful athlete who puts all effort into study, the disappointed 
husband who turns all efforts to success in business or club work, all 
provide examples of compensatory adjustment in action. Much of the 
compensatory behavior is healthy and leads to accomplishment that 
might not otherwise have been attained. In many instances, however, 
the compensations are hit or miss affairs in which there is little oppor- 
tunity for success. The manic attacks may sometimes be viewed as 


compensatory reactions for a developing depression, and semi-compul- 
sive rituals are substitutes for behavior that produces anxiety. 
Hypochondriacal, hysterical complaints may also be viewed as com- 
pensatory reactions to loss in self-esteem and failure in accomplishment. 

Rationalization. Rationalization is a form of defensive behavior in 
which the individual gives socially acceptable reasons for his actions 
and thus reduces his tensions and anxieties. Children learn very early 
by trial and error, by example, and indoctrination to give socially 
acceptable reasons for their inadequacies or failures. They learn that 
the free expression of certain of their motives will bring them rebuke, 
rejection and disgrace. They may, however, secure approval by assign- 
ing other motives to their behavior. As with other adjustive techniques, 
it is the subtlety of the operation of the rationalization that makes 
for its efficacy as a tension reducer. Thus the fictitious reason becomes 
acceptable not only to others but also to the person who is rationalizing. 
The individual is, therefore, learning to deceive himself as well as others. 
Rationalization is not only a part of the behavior of the average person 
but a very useful protective device. Its use, within normal bounds, 
makes unnecessary the analysis of every trivial motive. Certainly there 
is no necessity for the analysis of some motives and great danger in the 
development of the tendency to attempt to track down the origin and 
meaning of every item of one's behavior. The rationalization may thus 
enable one to maintain his self-esteem and confidence and protect him 
from his natural anxieties. The inability to rationalize is strongly 
noticeable in some depressed persons who are consequently unable to 
deny their real or imagined failures. 

The process may, however, be misused, and typical delusional be- 
havior probably best indicates its most distorted and exaggerated usage. 
In such behavior the individual appears to be unaffected by contra- 
dictions that are obvious and, in fact, uses such contradictions for 
the development of further rationalization. Hypochondriacal, neuras- 
thenic and hysterical patients also use their assumed incapacities as 
rationalization for failures in accomplishment. 

Projection. Projection is a defensive adjustment, somewhat allied to 
rationalization, by means of which one reduces the tension and anxieties 
by attributing one's own traits and motives to others. The projection 
may be either assimilative or disowning in type. In assimilative pro- 
jection one assumes, without sufficient evidence, that others are as he 
is and may regulate his behavior in accordance with such an assumption. 
The basic assumption that other people are like ourselves is formed in 


most individuals in early childhood. However, those who have con- 
siderable practice in sharing the perspectives of others will learn much 
about individual differences and will be less likely to imagine that their 
ways are the ways of everyone else. Those not so practiced in role 
taking are more likely, in times of personal stress, to assume that others 
know what they feel and think. 

In much the same way, the disowning projection develops as a means 
of protecting oneself from the unpleasant necessity of recognizing real 
or imagined failures, inadequacies and deficiencies. There one tends to 
attribute evil intentions and selfish motives to others and to disclaim 
them for himself. It is extremely unpleasant to fail to win the contest 
or to admit that the failure is due to one's own inadequacy. Conse- 
quently it is not surprising to find that one way to avoid the ego dis- 
satisfaction is to project the failure outside of the self. The individual 
who is reaction-sensitive to certain real or believed inadequacies may 
develop considerable conscience which is unbearable and which he 
habitually handles by projection. In extreme instances the individual 
may react to his accusing self reactions as if they were the part of a plot 
directed against him by others, and such tendencies may result in a full- 
fledged delusional system. Under other circumstances a person may 
react to his self accusations as if they were the voice of someone else and 
may consequently begin to hallucinate. 

Insulation and timidity. The adjustive techniques discussed so far 
have been primarily aggressive in type. One may, however, reduce the 
tensions of need and anxiety by retreat or withdrawal. Such with- 
drawals are normal when they do not interfere with social effectiveness 
and pathological when they affect perception of reality. 

Situations that arouse tension and threaten one with failure and 
humiliation may be met with avoidant responses of timidity, seclusive- 
ness, and insulation. In its simpler manifestations this behavior is 
simply an extension of the shrinking and hiding reactions of frightened 
animals. The effectiveness of insulation and seclusiveness is due to 
the fact that one cannot fail if one does not compete. 

Since the shy and withdrawing child does not upset the environment 
as does the aggressive child, the withdrawing maladjustments are more 
likely to go unnoticed. Such children are frequently described by 
parents and teachers as being good children who cause no trouble. 
The continuance of such behavior robs the individual of the opportunity 
to establish satisfactory interpersonal relationships and understandings 
through the usual processes of give and take relationships. Thus one 
is able to recognize in every society the extremely shy and distant in- 


dividuals who have developed special techniques for insulating them- 
selves from others and who stiffen and shy away from every friendly 

Negativism. Withdrawal or escape is not always a quiet and passive 
process. One may withdraw aggressively with refusal, stubbornness 
and rebellion. Negativism in the small child appears to begin with 
simple attempts to continue activity in the face of restraint. Such 
behavior develops easily into temper outbursts, breath holding, refusal 
to eat and a variety of attempts to do whatever is forbidden. Those who 
continue to gain decided advantage through negativistic behavior es- 
tablish habitual tendencies to respond in such a manner in times of 
stress. In older children and adolescents negativism is especially ob- 
vious in resistance to orders and readiness for argument and contra- 
diction. While one is not expected to comply with all of the rules and 
regulations of those in authority, many anxious individuals attempt to 
reduce their feelings of insecurity by habitual and unreasoning nega- 
tivism. The extreme use of negativism as a means of escape is seen 
most frequently in schizophrenic patients, but may also be seen in some 
cases of middle life depression and in cases of brain damage and de- 

Regression. One of the most natural methods of dealing with present 
tensions and dissatisfactions is to regress or go back to some earlier 
method or period which was more satisfying. This is another method of 
withdrawal or escape since the individual does not combat his difficulties 
but retreats to earlier and generally inferior types of adjustment. 
When present situations are frustrating, one tends to resort to habits 
that have been successful in the past. Thus the small child who feels 
insecure falls back on infantile behavior that formerly brought him 
maternal sympathy and attention. The maladjusted adult and adoles- 
cent may regress to childish behavior in the face of similar stress. 
Satisfactory living requires the gradual development of more mature 
methods of adjustment and the overcoming of infantile and childish 
dependency. Unfortunately many parents resent the growth of their 
children into mature and independent persons and handle them so as 
to keep them dependent as long as possible. 

Such over-indulgence and over-protection increase the likelihood of 
regressive behavior in situations of insecurity. Since regressive be- 
havior is a very common reaction to frustration, it will be in evidence 
in a variety of behavior disorders, but the most extreme manifestations 
are seen in certain schizophrenic patients. 

Fantasy. When real attainments and satisfactions are not forthcoming, 


all individuals derive some satisfaction through make-believe or fantasy. 
Day-dreaming is a perfectly normal adjustment that makes its ap- 
pearance very early in the child. Every normal child learns to derive 
some satisfaction out of make-believe and thus comes to derive some 
satisfaction in fantasies which are perhaps not possible in reality. The 
fantasy is more evident in the young child since he verbalizes his fantasies 
and sometimes even gives his make-believe playmate a name. As the 
child grows older, he realizes that one does not tell all of one's day- 
dreams, but he does not stop indulging in them. Some of such day- 
dreaming is valuable since it reduces tensions and brings satisfactions. 
Indeed much of it is indistinguishable from imagination, which is so 
important to the development of the child. A considerable part of the 
planning for tomorrow's accomplishments is developed through im- 
aginative dreaming. Indeed, creative thinking, which is responsible for 
new discoveries, is not completely distinguishable from fantasy. In 
normal day-dreaming, however, one either makes his dreams serve the 
purpose of making real accomplishment possible or uses them infre- 
quently for recreation and refreshment. 

The fantasy becomes dangerous when it becomes a satisfactory sub- 
stitute for real attainment or reduces the effort to attain satisfactions in 
reality. If one develops the habit of resorting to fantasy the moment 
that anxiety appears or that life seems dull or difficult, the fantasy has 
ceased to serve a useful purpose and is becoming pathological. The 
withdrawal from reality into the world of dreams is most dramatically 
seen in schizophrenic disorders, but the pathological use of fantasy is 
evident in many of the behavior disorders. 

Repression. Repression as an adjustive technique involves an at- 
tempt to reduce tensions by preventing occurrence of tension-producing 
reactions or by inhibiting recall. The individual learns to make avoid- 
ant responses to stimuli that suggest the recall of unpleasant experi- 
ences. He turns away from any external and internal stimuli that 
would suggest the recall of unpleasant situations. The repressions are 
not always complete, and in many such instances the tensions developed 
may be greater than those associated with the repressed situations. 
Incomplete repression, with emotional displacement, may be clearly 
observed in phobias, compulsive rituals and obsessive ruminations. 
In such situations the phobias, compulsions and obsessions have been 
substituted for the original anxiety excitants. These acquire their own 
anxiety components which the patient can discuss, but the original 
excitant has been repressed. Similar incomplete repressions are typical 


also of many of the hysterical manifestations, whereas complete re- 
pressions are more frequently seen in the schizophrenic disorders and in 
hysterical inactivation. 

In the psychotic and psychoneurotic disorders, frequent reference will 
be made to the use of the adjustive processes which have just been dis- 
cussed. We will find, for an example, that the schizophrenic patient is 
frequently referred to as "projecting" his failures on to some cause other 
than his own deficiency. His failure to succeed in a certain venture is ex- 
plained by him as being due to the fact that people in general, or some 
particular person or group of persons, are working against him. The 
mechanism of projection itself cannot, however, be said to be abnormal. 
The tennis player strokes his ball into the net or outside of the court and 
immediately proceeds to examine his racquet, projecting his own defi- 
ciency onto the racquet. The baseball "short stop" fumbles a ground 
ball and immediately examines his glove or throws a pebble out of the 
way. These individuals may not be conscious of their projections, but 
they are real just the same. It is, therefore, not the projection which is 
abnormal, but the degree of its manifestation. 

The schizophrenic is also often described as having regressed to child- 
ish behavior. Again, it is not the mechanism, but the degree of its use 
which is considered abnormal. Such remarks as "don't be childish," 
"act your age," etc., which are frequently heard in groups of adults, are 
indicative of the fact that the mechanism is employed by normals. The 
desire to return to childish delights is well indicated by the song, popular 
some years ago, "How'd you like to be a kid again." The consideration 
of the regression as abnormal occurs, then, as a result of the degree to 
which the schizophrenic carries it. Even the delusion of the paranoid 
individual who believes himself a great inventor, financier, statesman, 
warrior or even Jesus Christ must be thought of as an abnormal use of a 
normal mechanism. Day-dreaming must be viewed as a normal func- 
tion since all normals participate somewhat in it. The small child 
imagines that he has the toys and "goodies" which are not his in reality; 
the adolescent fancies in his day dreams that he is the hero on the foot- 
ball field or in the track meet, and even the adult builds his castles in the 
air and derives much pleasure from them. What makes the mechanism 
abnormal is the excessive use of it or the failure to be able to return to 
reality. The normal individual may even identify himself with some 
great personage in his day dream, but he is able to return to reality and 
recognize that he has been indulging in fanciful experiences. The ab- 
normal, however, reaches a point where he is unable to differentiate 


between fact and fancy, and so escapes to his world of dreams. What 
was at first fancy for him now becomes fact, or we may say he suffers 
a flight from reality. The mechanisms used by the abnormals are not 
different from normal reactions in kind but in degree, so that we have 
sometimes described the abnormals as being like us only more so. 
Another fact which should be kept in mind is that reactions are many 
times mentioned as abnormal without any careful consideration of the 
causes. If a small boy were to eat sand and later the matter were 
regurgitated, the action would be considered as normal for the cir- 
cumstances. In just the same way we must be able to recognize that 
certain reactions in our patients, despite the fact that they are unusual 
or peculiar, are what might be expected to occur as responses to their 
unusual experiences. 


With this explanation of the difference between the normal and the 
abnormal in mind, we may move on to study of the classification of the 
mental disorders with some attention to the history of the development 
of that classification. Since a complete treatment of this history would, 
however, involve a long and detailed discussion, only a brief summary will 
be attempted in this section. For a complete treatment of the history 
of medical psychology the reader is referred to Zilborg and Henry. (734) 

Primitive. Our knowledge of primitive conceptions of mental disease 
is less than fragmentary, although it seems certain that primitive man 
showed his fear by populating his world with spirits which were the 
images of his own anxieties. It appears that from the beginning, man 
looked upon everything that disturbed or enhanced his well being as the 
direct or indirect result of interference by spirits. 

Some of the imaginary beings were good or useful (as were some of his 
own impulses) and some were evil or injurious (like many of his own 
hatreds). In the formal thought of even very primitive people we en- 
counter the beginnings of dualism in the distinction between the body 
and the spirit. When mental illness appeared and the familiar per- 
sonality of the victim was transformed, it appeared to the onlooker as 
if some new being were present in the body. It was quite natural, 
then, that this being should be thought of as a demon or a spirit. In 
very primitive cultures a god was thought to be present so that the 
possessed attained great influence and his verbal productions were in- 
terpreted as good omens. 

On the other hand, the destructive tendencies and the highly in- 
dividualized activities of some of the mentally ill caused them to be re- 


garded as possessed of inimical spirits or devils. Sickness was all mental 
or spiritistic as the primitive man might have used the word. There 
was apparently no division into physical and mental diseases, all diseases 
being attributed to supernatural causes. The psychological energies 
were therefore directed more to getting rid of the uncertainty and fear 
generated by the illness than to efforts to eliminate the illness itself. If 
the sick individuals were believed to be possessed by good spirits, they 
were respected and worshipped; but those unfortunate persons who were 
believed to be possessed by evil spirits were beaten, burned, and starved 
in an effort to remove or destroy the demon. Since head injuries were 
common in primitive times it is not surprising to find that primitive 
man gave great significance to the hole in the head as it related to the 
possibilities for good or evil spirits to escape or inhabit the body. It is 
interesting, therefore, to note that crude trephination operations were 
performed to allow the evil spirits to escape. 

Ancient. The transition from magic to medicine was very gradual and 
led to many curious admixtures. The various ancient civilizations, even 
including the early Greeks, did not present conceptions of mental illness 
that differed markedly from those of primitive man. The trend of 
primitive man was still evident five thousand years before Christ in the 
days of Imhotep, the father of Egyptian medicine. The various medical 
papyri discovered in Egypt contain strange medicines such as fly specks, 
the fat of animals, and excreta of crocodiles; but there were also drugs 
of indisputable virtue castor oil, opium, gentian and many others. 
To be sure, the special virtue of these was poorly understood, and all 
medicines were used with priestly incantations and charms which prob- 
ably did little harm (other than obscuring the opportunity for advancing 
knowledge) and might have done some good. Music, as well as magic, 
was used by the Egyptians for dealing with the evil spirits assumed to be 
responsible for the mental disorders. The music was used by priests 
and magicians both to quiet the patient and to lure the evil spirit from 
the body. 

Among the Hebrews of the scriptural ages there are recorded a large 
number of clinical descriptions of mental illness. Saul suffered from 
recurrent depression, both homicidal and suicidal, and the disease, 
manic-depressive in character, is attributed to evil spirits from God. 
"But the spirit of the Lord departed from Saul, and an evil spirit from 
the Lord troubled him". 1 These attacks recurred, and in between them 
were manic-like episodes. In the depressive phase he was self-ac- 

1 i. Samuel, Chapter 16, verse 14. 


cusatory, suspicious and much troubled. In the excited phase he 
"stripped off his clothes also, and prophesied before Samuel in like 
manner, and lay down naked all that day and all that night". 2 Hannah, 
the mother of the prophet, Samuel, was apparently afflicted with a severe 
neurosis, and the ecstatic states of some of the prophets are suggestive 
of pathological mental states. The understanding of mental disorders 
and the treatment of those afflicted did not depart much from tradition. 
The Bible quotes Moses as saying: "The Lord shall smite thee with 
madness, and blindness and astonishment of heart" 3 and again in Leviticus 
it is stated that "A man also, or woman, that hath a familiar spirit, or 
that is a wizard, shall surely be put to death: they shall stone them with 
stones; their blood shall be upon them". 4 Physicians and priests were 
the mental healers, and the therapeutic measures consisted mainly of 
prayer, magic, music and exorcism. The disorders were generally con- 
sidered to be forms of punishment for incurring the wrath of God. 

The earliest Greeks were probably no less superstitious than the 
Egyptians or the Hebrews. Their underlying philosophy was that of 
primitive religious dualism, and people suffering from fits and other 
symptoms were believed to be possessed of evil spirits. Aesculapius is 
traditionally considered the god of medicine, and the medical centers of 
the pre-Hippocratic days were the Aesculapian Temples. The practices 
were markedly artful, and the treatment began with imposing religious 
ceremonies. A form of dream interpretation may be noted since the 
patients were required to sleep near the temple and dream of a god 
appearing and producing the miracle of the cure. Not all of the mentally 
ill were recognized as being sick, and some were even chosen to interpret 
and cure human ills. Some of them were taken into the temple to be 
healed, or even to do the healing, while others were refused admittance 
and were stoned. 

Greek medicine, however, begins with Hippocrates, who renounced 
the mystical and spiritual concepts of disease. Here almost completely 
removed from magical supersitition, we have diseases studied in their 
natural history, with descriptions of their symptoms, signs and causes. 
The works of Hippocrates probably do not all proceed from one pen. 
Rather they indicate the rise of an objective scientific school of medicine, 
independent of, and opposed to, the priestly superstitions of the Aescul- 
apians. Hippocrates is credited as the first to emancipate medicine from 

2 i. Samuel, Chapter 19, verse 24. 

3 Deuteronomy, Chapter 28, verse 28. 

4 Leviticus, Chapter 20, verse 27. 


religion and magic. He robed the priests of even the "sacred disease", 
epilepsy, holding it to be no more sacred than any other illness. He 
recognized the brain as the organ of thought and attributed mental 
illness rather to disturbances in the brain than to possession. He was a 
keen clinical observer, and his descriptions of some clinical types would 
be excellent even today. His views were liberal and flexible, and his 
psychological theories were in no sense one-sided. Depending upon the 
case and the occasion, he sometimes favored a purely anatomical view, 
represented by the extreme organicists of today, who believe all mental 
disease to be the result of brain injury. In other cases he favored the 
physiological theory represented by some of the endocrinologists of 
today, and yet at times he believed that purely mental emotional states 
may produce deep changes, even physiological, in the individual. The 
humoral theory of physiology and of temperament arose among the 
later Hippocratic writers and constitutes one of the earliest attempts at 
personality classification. 

The early Romans associated mental disease with the presence of 
demons, and mental healing was chiefly in the hands of the priests. 
At about 150 B. C. many scholars began to migrate to Rome, and for a 
while Rome became the center of scientific productivity. There was no 
further great original contribution to the field until the appearance of 
Asclepiades. He was one of the first serious and humane students of 
mental illness. He, as did Pinel, eighteen centuries later, advocated 
opening the dungeons in which the insane were housed and treating them 
with sunlight, music and gentleness. He described frenzy, lethargy, and 
catalepsy in clear terms. He invented ingenious devices to make the 
patients more comfortable, prescribed many kinds of baths and objected 
violently to bleeding, which he considered equivalent to strangling. 
His psychiatric contributions served as one of the indications that Rome, 
toward the close of the pre-Christian era, was passing through a period 
of humanism in medical psychology. 

It should be kept in mind that at this time the only advanced culture 
was on the shores of the Mediterranean, and only the privileged few had 
access to knowledge. In the background was the mass of people, as 
always, with their superstitions. It was during the first century that 
Christ and his disciples were curing the halt, the dumb and the blind by 
casting out devils, and mental illness in general was treated in terms of 
demonological possession. 

Contrast the above with Aretaeus, who studied all sorts of nervous 
and mental disease and described both the symptoms and mental changes 


in epilepsy. He discussed melancholy in terms that are in many respects 
close to our modern concepts. Distinguishing between melancholia and 
mania, he nevertheless considered a connection between them. He also 
recognized that such states are prone to recur, and he did not fail to 
observe that some conditions beginning as melancholia went on to 
deterioration. Soranus, the greatest physician of this period, was pri- 
marily interested in obstetrics and gynecology but paid considerable 
attention to mental disease. Soranus differentiated those deliria due to 
fever and described the behavior in some detail. He observed fever in 
some manic states and noted that in mental illness due to fever, the 
fever precedes the excitement. He observed the occurrence of stupors 
with immobility and waxy flexibility. He criticised the therapeutic 
measures that had been in use and described new treatments which 
emphasized his humane point of view. 

Galen (c. ijo-c. 200 A.D.), the last great physician of the Greek period, 
combined the scientifically founded principles of his day with careful 
administration of available medicines and sympathetic treatment of the 
patient. Following the death of Galen, the light of Greek learning 
flickered and failed, and the medical world entered the twilight of the 
Dark Ages. 

The Dark Ages. The ancients had moved forward a great distance 
when they recognized mental illness as something going on within the 
individual, a disease some of the causes of which could be recognized. 
The first three centuries of the Christian era, however, even before the 
establishment of Christianity as a political and spiritual instrument, 
were marked by the rise of superstitious beliefs and a revival of the 
primitive concepts that the mind is unlike the body and divorced from 
it. The whole field of mental disease was torn away from medicine, 
and man came again to believe in demoniacal possession, sorcery and 
magic. Official Christianity attempted to combat the practice of magic, 
but was helpless in the face of its own dogmas since the Christian fol- 
lowers did not deny the existence of the supernatural beings postulated 
by the magicians. Medical psychology as a therapeutic art ceased to 
exist as religious miracles were sought as cures. European medicine 
descended to the levels of charms and incantation, amulets and magic. 
Thus it did not differ, in principle, from the demonological concepts of 
the earlier Chinese and Egyptians, even though cloaked with the sacred 
robes of the church. Psychiatry had become the study of the ways and 
means of the devil and his cohorts. Whatever was preserved of the 
Greek achievement was perpetuated, and later distorted, in Arabia or 


buried in churches and monasteries. During the Middle Ages the 
Arabian physicians began drifting back into Europe, where they repre- 
sented what scientific medicine there was. This was Greek medicine as 
it had become modified by oriental astrology and magic. 

The general attitude toward mental diseases in the thirteenth and 
early part of the fourteenth century was very confused. The physicians, 
confronted with a psycho-pathological problem, attempted to put to- 
gether the traditional physiologies of old Greece and Alexandria and the 
astrology, demonology, and simple prayers of their own time. Witches 
were thought to be responsible for impotence, loss of memory and a 
variety of types of pathological behavior. Man frequently took it upon 
himself to mete out to his own body the punishment which he believed 
the Lord wished him to endure, and self-torturing sects made their ap- 
pearance over much of Europe. 

The universal anxiety of the fifteenth century was most completely 
expressed by two Dominican brothers, Johann Spranger and Heinrich 
Kraemer, who methodically set but to lead a movement for the exter- 
mination of witches. These two theologians wrote a book entitled 
"Malleus Malficarum The Witches' Hammer" which was destined 
to become the most horrible and authoritative document of the age. 
Under the influence of the Malleus, witchcraft became a pious sounding 
rationalization for anything which any one opposed or wanted to 
destroy, and hundreds of thousands of mentally sick fell victim to the 
violent movement. 

While little progress was made in the treatment of the mentally ill 
during the Renaissance, the ground work was laid for a satisfactory 
understanding of psychological motivation. The psychologists did not 
reach scientific maturity in the consideration of human impulses, drives 
and emotions until the last years of the nineteenth century when Freud 
published his formulations. Nevertheless, Juan Luis Vives, a man who 
lived three centuries before Freud, clearly anticipated many of the later 
ideas. He was the first to point out and describe the importance of 
psychological associations, to recognize the emotional origin of certain 
associations and their ability to revive long forgotten thoughts, sen- 
sations and emotions. Although credit is usually given to Hartley 
and Hobbs for the discovery of associations, it is clear that Vives, a 
century before Hobbs, gave evidence of his understanding of associations 
and their relationship to remembering and forgetting. Vives anticipated 
Freud in many ways, describing the egotistic drives of man and dis- 
cussing active and passive love in a way that was almost Freudian. 


He made definite statements regarding the puzzle of double feelings 
and of the clash of mutually conflicting affects, a phenomenon which 
was considered illogical before Vives and for a considerable period after 
him until Bleuler, following Freud, introduced the term ambivalence. 

Paracelsus and Weyer were others whose contributions were im- 
portant during this period. Paracelsus rejected demonology and at- 
tacked witchcraft. Weyer anticipated many later developments and 
completed the process of divorcing medical psychology from theology. 
He clearly stated many progressive and humanistic concepts of modern 
law such as that of the "irresistible impulse". 

In the seventeenth century great strides were made in neuro-anatomy, 
neuro-physiology and neuro-pathology, but there developed a separation 
of psychiatry from psychology. Psychology lost favor with medicine 
and was delivered into the hands of speculative thinkers. Bacon, 
Descartes, Hobbs, Locke, Malebranche and Spinoza carried the burden 
of concern regarding the role of volition and emotions in the actions of 

Mesmer, like Vives, must be credited with having been of great im- 
portance to the history of psychoanalysis. Although a student in 
medicine, Mesmer was greatly interested in the influence of the stars on 
mental health. He experimented with the use of magnetized plates for 
the treatment of mental patients, and when he noted that he could get 
the same beneficial results in his patients by substituting his hands for the 
magnetized plates, he developed a theory of animal magnetism which 
came to be known as Mesmerism. Mesmerism was vigorously opposed by 
the medical profession and Mesmer was generally considered a charlatan. 

James Braid, an English surgeon, studied Mesmerism and became 
impressed with the subjective factors of response to the magnetizer. 
He concluded that the mesmeric sleep was a subjective psychological 
state induced by visual fixation. He introduced the new terms, hyp- 
notism, hypnotize and hypnotic. In 1860 Liebeault, a French country 
doctor, began to study hypnosis and to use it for both treatment and 
research. The further development of hypnosis for the treatment of the 
mentally ill awaited the work of Charcot and Bernheim, who were to 
dignify hypnosis and to stimulate the work of Sigmund Freud. 

In the meantime the attitude toward those who were mentally ill 
was being affected by the social and political changes of the time. Pro- 
gress was being made in every country in Europe, as well as in America, 
in the care of the mentally ill. The fact that King George III suffered 
from a mental disorder served indirectly to make for better care of the 


mentally ill. Although the King was treated by England's best physi- 
cians, there are indications that he did not escape the brutal treatment 
which was characteristically given in such cases. This brutal treatment 
led to parliamentary investigations and to protective legislation which 
provided for more humane care of the English mental patients. 
Throughout the entire previous period, the lot of the mentally ill had 
been deplorable in the extreme. The belief in possession had led to the 
confinement and chaining in dungeons of many people; some were stoned 
and driven out to fend for themselves in the woods; others were burned 
at the stake as witches. The place of confinement was often enough a 
prison dungeon in which the convicts were the keepers of the insane. 

The progress of medicine brought little help to the mentally ill until 
the eighteenth century in which both the American and French Revo- 
lutions occurred. The way was prepared for these upheavals by the 
humanitarianism of such men as Voltaire, Montaigne, Rousseau and 
others. The American Revolution was largely an attempt to secure 
political and religious freedom, but the French Revolution grew out of 
oppression by the nobility. It is not surprising that simultaneous with 
these broad movements a revolution took place in the management of the 
insane. This change in attitude had its first tangible effect when the 
first modern hospital for the treatment of the insane, the Asylum of St. 
Boniface, was built in Florence. The patients were no longer huddled 
together, chained or confined in cells and dungeons, but were treated 
kindly and given medical care. Real impetus was given to the move- 
ment when Pinel assumed control of the Bicetre Asylum in Paris in 
1792. There Pinel struck the chains from the mentally ill and led them 
into the sunlight and fresh air for exercise. Together with his pupil and 
colleague, Esquirol, he brought about a general improvement in the 
asylums throughout France. Almost simultaneously with Pinel, a tea 
merchant of York projected the founding of a Retreat for the mentally 
ill under the auspices of the Society of Friends. The building was 
called the "Retreat" in an effort to avoid the stigma usually associated 
with the terms "lunatic asylum" and "madhouse". The institution was 
built in 1796 and resulted in calling attention to the flagrant abuses then 
prevalent in England. Emphasis was placed on the treatment of mental 
patients as guests rather than as inmates, and the place stood out in 
strong relief against the practice otherwise in England where the ment- 
ally ill were chained in cells, exhibited to the curious public for a small 
fee on holidays, and left naked and uncared for. 

In America during Colonial times the handling of the mentally ill 


had followed the pattern set in Europe, and consequently the insane were 
persecuted as agents of the devil and witches were hunted out and burned 
at the stake. The first institution for the exclusive use of mental 
patients was built in Williamsburg, Virginia, in 1773, and it remained the 
only such institution until 1824 when another state hospital was opened 
at Lexington, Kentucky. While Pinel and Tuke were humanizing the 
treatment of the insane in Europe, Benjamin Rush, the father of psy- 
chiatry in America, was introducing similar reforms in America. He 
emphasized humane care, separated the sexes, restricted the use of 
mechanical restraints, and introduced occupational therapy and exercise 
for the patients. 

Once the patients were hygienically housed under the care of in- 
terested and competent physicians, the opportunity was at hand for 
careful observation and study of their illness, and scientific advance 
became possible. Demonology had run its course, and the patients were 
again in the hands of medical physicians. While the disorders were no 
longer believed to be caused by evil spirits, there was still no real under- 
standing of the functional mental illness. Although the somatists had 
won the ascendancy and mental illness was, in general, assumed to be 
due to physical organic changes, the most exciting changes in under- 
standing and treatment were still to come. 

Modern Period. During the nineteenth and twentieth centuries, 
important changes in the understanding of mental illness came so 
rapidly, that the names of the contributors are too numerous for mention. 
Griesi-nger, however, sounded the death knell of the demonological 
school when he published his works in 1845 bringing together clinical 
observation, psychological analysis, and physiological and pathological 
changes. The Hippocratic doctrine that mental illness is the result of 
brain disease was restored and has had a powerful influence up to the 
present time. There are still those who maintain that organic pathology 
will finally be shown to be the cause of what are now called functional 
disorders. The philosophical foundation of the somatic school lies in 
dualistic (psycho-physical) parallelism (which holds that every mental 
change must have its physical cause), or in materialistic-mechanistic 
monism. The rapid advances in neurological and neuro-physiological 
research strongly entrenched this organic point of view. The inability 
of the physician to point out the organic lesions responsible for certain 
disturbances led to the postulation of functional etiology for these 
conditions. Thus Charcot took the position that a morbid idea could 
produce an hysterical symptom. 

By the nineteenth century a number of German physicians were 


making history in the study of mental illness. The outstanding contri- 
bution of this group was made by Emile Kraepelin. His classification 
of mental illness is a landmark in objective psychiatry and is still the 
basis of most present day classifications of mental disease. Kraepelin's 
classification was a symptomatic one and involved minute subdivision 
and detail. He made very systematic and descriptive presentations of 
clinical material, and he made good use of his experimental training in the 
study of abnormal behavior. 

The most exciting discoveries, however, were those stemming from the 
work of Vi ves and championed by Paracelsus three hundred years earlier. 
Mention has already been made of the contributions of Mesmer, Braid, 
Charcot and Liebeault. Charcot was a highly respected French physi- 
cian, competent in organic medicine, and his position, therefore, was not 
likely to be challenged by organicists. He explained hypnosis in terms 
of physiological processes and viewed it as a manifestation of hysteria 
which he believed to be a disease of the nervous system. The value of 
his work was principally the stimulating effect that it had on many 
later students such as Janet and Freud. While Charcot dignified the 
use of hypnosis, he was not cognizant of the fact that the symptoms of 
hysteria could be learned by the patient. 

Bernheim raised many objections to the theories of Charcot. He 
pointed out that Charcot had failed to note that many of the patient's 
manifestations were the result of the hypnotist's inadvertant suggest- 
ions and not the nature of the disease. He called for greater study of the 
process of suggestion and recognized that it was not limited to hysterical 
persons. He pointed out that hypnosis was closely related to sleep and 
could be produced in many normal persons, and his success in the use of 
hypnosis as a treatment for hysteria brought him many students. 

One of Charcot's foremost pupils was Pierre Janet, who popularized 
the notion that the psychoneurosis was the result of a constitutional 
weakness of the nervous system. Janet used hypnosis as an investi- 
gating technique and developed a dissociation theory of personality 
which was later greatly elaborated by Morton Prince. For Janet, the 
personality was a systematic integration of ideas and tendencies which 
remained relatively stable. The neurotic personality was characterized 
by the dissociation of these tendencies brought on by the exhaustion or 
emotional strain and dependent upon a constitutional weakness. While 
he developed a systematic psychological explanation for many neurotic 
disorders, his premise exercised a deadening effect on therapy since the 
neurosis was viewed as a natural consequence of a biological handicap. 

The most prominent of all of Charcot's pupils was Sigmund Freud. 


He had been early associated with Breuer, a general practitioner in 
Vienna, who was treating his neurotic patients by hypnosis. Breuer 
had been allowing his patients to talk about their illness under hypnosis 
and had noted that in doing so they displayed a good deal of emotion and 
were much relieved when they awakened. Freud became interested in 
Breuer's methods and went to study Charcot's work on hysteria at the 
Salpetriere in Paris. Later Freud used hypnosis only in order to permit 
the patient to speak spontaneously and to discharge the emotions con- 
nected with his fantasies. Because of the regular discharge of the 
emotions, the method was called catharsis. Freud soon discovered, 
however, that if he dispensed with hypnosis and let the patient talk at 
random, the patient overcame some of the inner obstacles that stood in 
the way of remembering. This new method was called free association, 
and the method of analyzing and interpreting what the patient said and 
did was elaborated into the system of psychoanlaysis, which has been 
discussed earlier in the text. The further development of psychotherapy 
has continued to stem from the concepts of Freudian psychoanalysis. 
The contributions of Freud's two most celebrated pupils, Jung and 
Adler, have been given attention at other places in the text, and the 
contributions of other Freudian pupils are too voluminous to be re- 
counted here. 

While great strides were being made in the development of funda- 
mental concepts for the understanding of the mentally ill, there was a 
considerable lag in the care and treatment of patients. In America, 
despite the fact that a number of mental hospitals had been erected 
during the early nineteenth century, many patients were still housed in 
jails, prisons, and almshouses and were ill-fed, poorly clothed and bruta- 
ally treated. About the middle of the nineteenth century, Dorothea 
Lynde Dix began a movement which exposed and eventually improved 
the deplorable and shocking conditions. For many years Miss Dix 
traveled all over America and abroad demanding adequate and humane 
care for the mentally ill. She was eminently successful in her efforts 
and was largely responsible for the development of the state mental 
hospital system in America. Soon after Miss Dix's campaign got under 
way, 13 mental hospital superintendents organized the Association of 
Medical Superintendents of American Institutions for the Insane, 
which was the forerunner of what is now known as the American Psy- 
chiatric Association. In 1895 t ^ ie Pathological Institute of the New 
York State Hospital was established as a center for research and clinical 
observation. In 1902 the name was changed to the Psychiatric In- 


stitute, and Adolph Meyer was appointed as the Chief psychiatrist. 
Meyer immediately organized a training course for psychiatric interns, 
and the institute became the center of psychiatric training in the United 
States. Meyer remained at the Institute until 1910 when he became 
professor of psychiatry at The Johns Hopkins University. He was the 
foremost proponent of holistic and evolutionary views in regard to 
mental disease. In 1911 he coined the word psychobiology to encompass 
the idea that we are working with the biological functions of the total 

He considered mental illness to be an illness of the total person in 
distinction from the part (organ or system) illness with which medical 
men are generally on more familiar terms. If these illnesses did not so 
often have topical etiological agents such as bacteria, poisons or physical 
traumata, they have, in common with all biological phenomena, a natural 
history which can be objectively studied,, understood and modified to 
advantage. His position that a mental disorder represented a malad- 
justment of the entire personality in relation to its environment had far- 
reaching influence, and from it developed the therapy known as dis- 
tributive analysis and synthesis. 

The contributions of Pavlov, the Russian physician and physiologist, 
in relating the conditioned reflex theory to the understanding of psycho- 
pathology have been discussed in an earlier chapter. It should further 
be noted that Pavlov led the way to the study of the experimentally 
induced neurosis in animals. 

Meduna, Sakel and Cerletti and Bini pioneered the development of 
the various shock therapies that have gained prominence in the last 
fifteen years. Meduna began convulsive treatment of schizophrenia in 
1928 using camphor in oil to induce the seizure. Finding camphor 
undesirable as a convulsant, Meduna later perfected the technique of 
using metrazol to produce shock and convulsion. 

At about the same time Sakel observed that accidental insulin shock 
in drug addicts resulted in the disappearance of schizophrenic like 
symptoms. He therefore developed a method of using shock doses of 
insulin for schizophrenia and other psychotic conditions. 

A few years later Cerletti and Bini, working in Rome, developed a 
method of treating patients by electrically induced convulsions. All 
of these methods of shock therapy are being extensively used in the 
treatment of mental patients. 

While the care and treatment of the mentally ill is of utmost im- 
portance, the greatest hope for the future lies in prevention rather than in 


cure. The prevention movement, oddly enough, got its impetus from a 
former mental patient, Clifford W. Beers. He was for three years a 
patient in both private and state hospitals, and upon his discharge from 
the hospital he decided to devote his life to the improvement of the 
conditions in mental hospitals and the prevention of mental disorders. 
He wrote about his illness and the conditions surrounding it and secured 
the help of many prominent men, including William James and Adolph 
Meyer, in the development of his plans. Meyer suggested that he apply 
the term "mental hygiene" to his projected movement. Beers assisted 
in the founding of the Connecticut Society for Mental Hygiene in 1908 
and pushed for the development of a national organization. In 1909 
the National Committee for Mental Hygiene was organized with Beers 
as its first secretary. Since that time, the mental hygiene movement has 
had a considerable growth, and a number of by products such as child 
guidance clinics have been established. The child guidance movement 
developed primarily from the impetus given by William Healy, who 
established the Chicago Juvenile Psychopathic Institute in 1909; but 
full maturity awaited the more complete development of the National 
Committee for Mental Hygiene. Mental Hygiene clinics associated 
with the schools or the courts and as civil projects rapidly followed in 


The history of the development of an understanding of mental disorders 
will indicate many reasons for the difficulty of present day classification 
of such diseases. The classifications have undergone many changes and 
are always in the process of revision. The early and medieval notions 
of good and evil spirits emphasized the position that all mental disorders 
were "mental" in origin. The physiological and endocrinological 
studies, on the other hand, made clear the fact that certain mental dis- 
orders were caused by organic changes occurring within the individual. 
The advocates of both points of view continue to offer evidence to 
support their positions. This is indicated by the attempts of one group 
to treat schizophrenia by psychoanalysis and the attempt of another 
group to treat the same disorder by shock and psychosurgery. 

The classification system now in use stems primarily from Kraepelin 
(735) and is basically symptomatic in type. This type of classification 
has been extensively used, probably because it involves merely the 
observation and recognition of the behavior symptoms of the patients. 
Such a classification serves a very definite need, but it tells nothing 


about the causes of the disorder. It is one thing to be able to name a 
patient's malady and another thing to be able to prevent or cure it. 

If we were able to demonstrate the underlying pathology of all of our 
cases, the problem of classification would be solved, but unfortunately 
this is not possible at the present time. The psychiatrist has erred 
frequently in his classifications because of ignorance of underlying path- 
ology. It is, for example, comparatively recently that paresis has been 
shown to have an organic basis. The symptoms, originally supposed to 
be functional or of psychogenic origin, may now be definitely referred to 
the organic changes in the development of syphilis. The continuation of 
the study and the development of scientific technique will undoubtedly 
bring to light the pathology of other disorders. 

The hope of the future in psychiatry, however, lies in prevention, and 
consequently in an understanding, of the causes of the disorders. In 
all considerations of etiology we must consider several factors and above 
all recognize the fact that the disease processes are the end results and 
therefore explainable not in terms of one of the factors, but in the 
combination of all of them. In other words, a mental disorder is the 
result of a long series of processes, hereditary, congenital and environ- 
mental, and cannot be explained completely on a basis of any one of these 
factors. The difficulty may have begun in the unfertilized germ plasm; 
other causes may have operated in the fetal period; and still others may 
be found in the environment to which the organism is subjected. The 
classification of the patients according to causation of their mental dis- 
orders has certain definite and obvious advantages. The most impor- 
tant of these is that we may take steps to prevent the development of 
the disease as well as develop specific treatment. We must, however, 
recognize the limitations of this classification. Symptoms have been 
confused with causes with the result that the treatment succeeds in 
curing the symptoms, but the disease remains. This is undoubtedly 
true in a large number of cases of chronic alcoholism. The alcohol is 
withdrawn and the subject's body freed of its effects, but the individual 
does not return to normalcy as is frequently claimed. In many instances 
the alcohol is not the cause of his difficulties, but is merely a way out of 
his disturbing dilemma. It furnishes him a temporary escape from his 
real problem and should be considered a symptom rather than a cause. 

In any discussion of mental diseases on a basis of causation it has been 
customary to group the disorders into two major divisions, organic and 
functional psychoses. Under the term "organic" are inc'uded all of the 
disorders which are known to have a definite organic basis, while those 


whose origin is claimed to be psychogenic are called functional. The 
disturbances of thought, feeling and action may in some cases (organic) 
be definitely correlated with impairment of structure, while in other 
cases (functional) no such structural impairment can be shown. Cer- 
tain abnormal reaction patterns can, for example, be shown to be the 
results of toxic infections, glandular disturbances, brain injuries or bac- 
terial infection, etc. In other disorders, however, the functions are 
disturbed, that is the mental aberrations are present, but no structural 
injury or disorder can be shown. The available information that we 
have is not sufficient to merit the dogmatism that is frequently expressed 
with regard to the causation of these conditions. Paresis, as already 
mentioned, was originally described as a functional disorder but is now 
definitely recognized as organic, the result of a certain stage of syphilitic 
infection. Discoveries of this nature have led many to adopt a view- 
point of extreme organicism and to state that one can understand func- 
tion only in terms of structure. According to the extreme organicist, 
every mental disorder is the result of some definite injury to nervous ma- 
terial. For such investigators the inability to account for any mental dif- 
ficulties in terms of specific organic disturbances is due to a lack of knowl- 
edge. To the student of psychology, who understands the principles of 
habit formation and learning, such an extreme viewpoint will appear 
unsatisfactory. We know, of course, that a blow on the head, bacterial 
infection or glandular disturbance may condition an individual's later re- 
actions, and we know just as surely that terrifying or distressing exper- 
iences or the frustration of his desires may also condition them. Such at- 
titudes as suggestibility, negativism, suspiciousness are learned, that is, 
acquired, through experience. The personality must be considered as 
dynamic, constantly changing with each new experience, and the de- 
velopment of reaction patterns which are viewed as abnormal can be 
explained by the same laws used to explain normal habit formation and 
learning. The complex emotional life of the adult is built by transfer- 
ring the feeling from one object or event to another through the process 
of association. The child is afraid of only a few things, the adult has 
learned to fear many; the child does not have many attachments but the 
adult has transferred the feeling to a great number of things. The reac- 
tion patterns of the adult must be interpreted in terms of his experiences 
in life. 

With this in mind it should not be difficult to recognize that since the 
life experiences of individuals vary markedly, the reactions to these 
experiences may be expected to show extreme differences. Recognizing 


that glandular disturbances, deficiencies in cell nutrients, injuries to nerv- 
ous tissues and the introduction of bacteria and toxins may result in 
mental aberrations, we must not lose sight of the fact that the present 
behavior of any individual is also dependent upon his past life experi- 
ences. The fact that one patient's delusions are those of grandeur 
while another considers himself persecuted is suggestive of the impor- 
tance of environmental factors, and even in those disorders with a defi- 
nite organic basis we frequently see differences in reactions which can- 
not be explained in any other way. It is hoped, therefore, that though 
we may discuss the disorders as being organic or functional, depending 
upon which factors play the dominant role, the reader will understand 
that all factors must be viewed as having a definite part in the end result. 

Recently a great amount of material has appeared in the literature 
under the caption of psychosomatic medicine. The contention of the 
psychosomatic group is that when emotional factors are associated 
with organic disease, too little attention is paid to the emotional factors. 
It is claimed that while most physicians acknowledge the psychic causes 
of such physiologic phenomena as blushing, weeping, gooseflesh and 
vomiting, they nevertheless, find it difficult to believe that more pro- 
longed (chronic) disturbances of a physiologic nature can possibly be 
psychic in type. The psychosomatic studies show clearly that emo- 
tional factors are prominent in the etiology of many serious physical 
disturbances. The contributions of psychosomatic medicine have been 
presented in an earlier chapter and Weiss and English (736) present a 
good bibliography of the work in this field. It should be noted that 
the psychosomatic enthusiasts, like the extreme organicists, have, at 
times, overstated the point; but a real contribution is being made to 
the understanding of mental disorders. It may not be long before the 
disorders will no longer be classified as either organic or functional, but 
attention may be given to how much each case is organic and how much 
functiona 1 . 

Some confusion also exists regarding the distinction between the 
psychoses and the psychoneuroses. While there are some difficulties 
of differential diagnosis, the psychoses, in general, may be viewed as the 
more serious disturbances. Some differences between the two are readily 
distinguishable. The psychotics frequently show some disorientation for 
time, place and person. That is, they may be confused with regard to 
who they are, where they are, and may also have lost track of time. 
They are also frequently not in contact with reality and manifest dif- 
ficulty in separating the products of their imagination from the realities 


of life situations. They also frequently have hallucinations and delu- 
sions and are likely to be lacking in insight into their condition. 

The psychoneurotics, though sometimes just as seriously disabled, 
present less severe disturbances of their psychic life. They are usually 
well oriented for time, place and person. They do not suffer from hal- 
lucinations and delusions, and while they may indulge in fantasy, they 
are able to distinguish these fantasies from reality. They usually have 
relatively good insight in the sense that they recognize their condition, 
although they may be incapable of doing anything about it. 

Condensed Form of New Classification Adopted by the Committee on Statistics and 
Approved by the Council of the American Psychiatric Association 

1. Psychoses with syphilitic meningo-encephalitis (general paresis) 

2. Psychoses with other forms of syphilis of the central nervous system 

(a) Meningo-vascular type (cerebral syphilis) 

(b) With intracranial gumma 

(c) Other types 

3. Psychoses with epidemic encephalitis 

4. Psychoses with other infectious diseases 

(a) With tuberculous meningitis 

(b) With meningitis (unspecified) 

(c) With acute chorea (Sydenham's) 

(d) With other infectious disease 

(e) Post-infectious psychoses 

5. Psychoses due to alcohol 

(a) Pathological intoxication 

(b) Delirium tremens 

(c) KorsakofFs psychosis 

(d) Acute hallucinosfs 

(e) Other types 

6. Psychoses due to a drug or other exogenous poison 

(a) Due to a metal 

(b) Due to a gas 

(c) Due to opium or a derivative 

(d) Due to another drug 

7. Psychoses due to trauma 

(a) Delirium due to trauma 

(b) Personality disorder due to trauma 

(c) Mental deterioration due to trauma 

(d) Other types 

8. Psychoses with cerebral arteriosclerosis 

9. Psychoses with other disturbances of circulation 

(a) With cerebral embolism 

(b) With cardio-renal disease 

(c) Other types 

10. Psychoses due to convulsive disorder (epilepsy) 
(a) Epileptic deterioration 


(b) Epileptic clouded states 

(c) Other epileptic types 

11. Senile psychoses 

(a) Simple deterioration 

(b) Presbyophrenic type 

(c) Delirious and confused types 

(d) Depressed and agitated types 

(e) Paranoid types 

12. Involutional psychoses 

(a) Melancholia 

(b) Paranoid types 

(c) Other types 

13. Psychoses due to other metabolic, etc., diseases 

(a) With glandular disorder 

(b) Exhaustion delirium 

(c) Alzheimer's disease (presenile sclerosis) 

(d) With pellagra 

(e) With other somatic disease 

14. Psychoses due to new growth 

(a) With intracranial neoplasm 

(b) With other neoplasms 

15. Psychoses due to unknown or hereditary cause but associated with organic change 

(a) With multiple sclerosis 

(b) With paralysis agitans 

(c) With Huntington's chorea 

(d) With other disease of the brain or nervous system 

1 6. Manic-depressive psychoses 

(a) Manic type 

(b) Depressive type 

(c) Circular type 

(d) Mixed type 

(e) Perplexed type 

(f) Stuporous type 

(g) Other types 

17. Dementia praecox (schizophrenia) 

(a) Simple ty pe 

(b) Hebephrenic type 

(c) Catatonic type 

(d) Paranoid type 

(e) Other types 

1 8. Paranoia and paranoid conditions 

(a) Paranoia 

(b) Paranoid conditions 

19. Psychoses with psychopathic personality 

20. Psychoses w ; th mental deficiency 

21. Psychoneuroses 

(a) Hysteria (anxiety hysteria, conversion hysteria and subgroups) 

(b) Psychasthenia or compulsive states (and subgroups) 


(c) Neurasthenia 

(d) Hypochondrias! s 

(e) Reactive depression (simple situational reaction, others) 

(f) Anxiety state 

(g) Anorexia nervosa 

(h) Mixed psychoneurosis 

22. Undiagnosed psychoses 

23. Without mental disorder 

(a) Epilepsy 

(b) Alcoholism 

(c) Drug addiction 

(d) Mental deficiency 

(e) Disorders of personality due to epidemic encephalitis 

(f) Psychopathic personality 

With pathologic sexuality 
With pathologic emotionality 
With asocial or amoral trends 
Mixed types 

(g) Other nonpsychotic diseases or conditions 

24. Primary behavior disorders 

(a) Simple adult maladjustment 

(b) Primary behavior disorders in children 

Habit disturbance 
Conduct disturbance 
Neurotic traits 



Since the organic psychoses constitute over 40 per cent of the first 
admissions to hospitals in this country, they represent a major problem 
in the care and treatment of the mentally ill. Attention has already 
been directed to the fact that the organic causes for disturbances of 
psychological function are many and varied. The most frequent of these 
are: (i) infection: paresis, epidemic encephalitis; (2) intoxication: al- 
cohol, drugs, exogenous poisons; (3) trauma: severance of nervous tissue 
by mechanical insult; (4) endocrine dysfunction; (5) circulatory or blood 
stream conditions: arteriosclerosis; (6) neoplastic conditions: tumors, 
thickening of meninges. All of these conditions may bring about some 
degree of brain injury which results in disturbances of psychological 
function. Some of the agents attack the brain tissue directly while 
others produce their effects on the nervous tissue indirectly. The de- 
velopment of psychotic behavior appears to be dependent upon injury 
or damage to the cerebral cortex, although damage to subcortical areas 
and other parts of the nervous system may result in marked disturbances 
of consciousness. Experimentation on animals and clinical evidence 
with patients tend to support the position that the psychosis develops 
primarily after gross lesions or the destruction of diffuse areas of the 

The organic reaction types may be either acute or chronic. The 
acute reaction is usually the result of a temporary toxic process af- 
fecting the brain tissue, such as the delirium accompanying acute fevers. 
The chronic reaction is the result of more severe tissue damage usually 
showing progressive deterioration, as in the senile psychosis. 

The acute reactions usually include disorientation, hallucinations, and 
false perceptions accompanied by a memory defect mainly for recent 
events. There is, however, usually no profound personality change. 

The chronic reaction more frequently shows profound personality or 
character changes that are progressive. Memory for both recent and 
remote events is affected, and comprehension is disturbed. 

No attempt is made here to give a complete account of the organic 
disorders, but a brief discussion is presented of the most important ones. 



In some instances the mental disturbance is pronounced enough to be 
called psychotic, while in other instances the loss of intellectual and 
emotional control and the disturbances of other functions may not be 
extensive enough to justify such a diagnosis. 


The etiology of the toxic psychoses is direct and usually ascertainable 
as: an exogenous poison like alcohol, morphine, or lead poinsoning; 
endogenous, as in the course of acute infections; and loss of metabolic 
support of the brain, as in endocrine disorders. It is our purpose here 
to discuss the first of these conditions; namely, the psychoses and 
personality disorders associated with alcohol, opium, morphine, cocaine, 
marijuana, barbiturates, gases, bromides and metals. The disorders 
are the results of elements which penetrate the body by way of the 
blood stream and attack vulnerable brain tissues. The extent of the 
disorganization of the personality depends upon the quantity of the drug 
ingested, individual tolerance, and various other factors. The incidence 
of mental disorder associated with alcohol and drugs is increasing, but the 
understanding of the problem is complicated by the fact that the use of 
alcohol and opiates is quite often a symptom as well as a cause of mental 

Alcoholic disorders 

The excessive use of alcohol is frequently encountered in those who 
seek psychiatric treatment, and consequently the reasons for taking 
alcohol as well as the effects of alcohol deserve careful scrutiny. Al- 
though alcohol is frequently thought of as a stimulant, all experimental 
evidence indicates that it is a depressant resulting in the impairment of 
both muscular coordination and mental efficiency. As Emerson (737) 
has indicated, alcohol, unlike food, passes from the stomach and in- 
testine into the blood stream in exactly the same form as taken into the 
mouth. From the blood stream it is carried into the heart from where 
it passes to the brain as well as to every other organ and tissue of the 

A variety of reasons for the taking of alcohol have been presented. 
In some instances alcohol is taken to conform to the social pattern or to 
be sociable, to experience the physiological or psychological effects, to 
escape from troublesome problems or conflict situations, or to satisfy 
physiological needs. What remains to be explained is why some indi- 
viduals must turn habitually to alcohol. There is a growing tendency 


to favor the position that the alcoholic has been emotionally mal- 
adjusted long before he became alcoholic and that the alcohol is a 
symptom of the personality disorder. Thus the drinking is viewed 
as a means of escaping from long standing insecurity. Schilder (738), 
along with other investigators, has insisted that the roots of alcoholism 
are the insecurities of early childhood. Many psychoanalytic investi- 
gators have emphasized the role of repressed homosexuality in the 
etiology of alcoholism. Whether alcoholism is symtomatic of a major 
personality defect or develops out of other causes is difficult to answer 
in every case, but there appears to be ample evidence for the fact that 
many insecure people use alcohol as a means of escape from their ten- 

Specific alcoholic mental disease may take several forms, but the 
three main clinical types are delirium tremens, chronic alcoholism and 
Korsakow's psychosis. 

Delirium tremens. This disorder rarely occurs before thirty years of 
age, and, as the name suggests, is characterized by generalized tremors, 
chiefly of the facial muscles, tongue, and fingers, and a state of delirium. 
The patient finds it very difficult to sleep and, if sleep is induced, he has 
vivid nightmares. There are vivid hallucinations most frequently 
visual, but also haptic and auditory. The usual visual hallucinations 
are of snakes, rats and elephants. The haptic hallucinations are usually 
of animals crawling over the skin and are probably based on paresthesia. 
The condition usually follows a "drunken bout" but may occur in a 
chronic alcoholic following acute illness or sudden injury. There is great 
restlessness and fear, and at the height of the delirium, frequently com- 
plete disorientation. Suicidal or homicidal attacks may be present 
in response to the hallucinations. 

Chronic alcoholism. The chronic alcoholic is the habitual drinker 
who suffers deterioration of intellect and character. The characteristic 
physical degenerations are well known and include tremors, paresthesia, 
circulatory and gastro-intestinal disorders, cirrhosis of the liver, gastri- 
tis, nephritis and generalized arteriosclerosis. Impotence resulting from 
the poisoning of the nervous system is frequently present. 

The intellectual and moral deterioration is no less disturbing. There 
are loss of memory, impairment of judgment, inability to concentrate 
and sometimes disorientation. Since the higher inhibitory centers are 
paralyzed, the patient acts in accordance with his present mood without 
the possibility of sound judgment. He becomes irresponsible, shiftless, 
careless, and is many times found bewailing his fate and stating that 


everyone is against him. Some authorities have attempted to show that 
a large percentage of chronic alcoholics are essentially homosexual, but 
though homosexuality is frequently a factor, it should be kept in mind 
that it is only one of many possible factors. 
As Henderson and Gillespie (739) have stated: 

The psychological understanding of a chronic alcoholic is an individual affair, and each 
case must be tackled as a special problem on its merits. The factors which have helped to 
precipitate a chronic alcoholic habit and to sustain it do not differ in any kind from those 
producing any other morbid mental reaction; and sufficient weight should be given to the 
influence of habit, to the influence of nagging friends and relatives in accentuating it and 
to the manner in which the alcoholism becomes a part of the ego-ideal, so that to keep on 
drinking becomes a point of honour. 

It is our belief that the psychopathology of alcoholics is most fre- 
quently represented by emotional immaturity. The individual who 
has been prevented, by parents and others in his environment, from 
making mature emotional adjustments frequently becomes alcoholic. 
The alcohol is easily obtained and quickly takes him away from un- 
pleasant realities and allows him to regress to lower emotional levels. 

Korsakow's psychosis. This syndrome, first described by Korsakow, 
seldom occurs before fifty years of age, is commoner in females than in 
males, and is usually of sudden onset. 

The disorder is generally of alcoholic origin, but sometimes it follows 
the toxic vomiting of pregnancy or is the result of lead poisoning, typhoid, 
malaria, or influenza. 

It is characterized by loss of memory, particularly for recent events, 
and retrospective falsification. The patient frequently forgets what 
happened just a few minutes ago, and is extremely susceptible to sugges- 
tion. With these elements as a basis, the patient also displays disorien- 
tation, especially for time, visual and auditory hallucinations and com- 
plete lack of insight. Further symptoms, characteristic of alcoholic 
polyneuritis such as abolition of the tendon reflexes, tenderness over the 
nerve trunks, pains and hyperesthesias of certain muscular regions, occur 
in an association with the disease, while in pronounced cases nystagmus is 
frequently present, and in some instances there is wrist or foot drop. 

The course of the disorder is usually a long one, and the prognosis is 
poor. Those cases of alcoholic origin often begin to show some improve- 
ment in about the sixth or eighth week, but many take a considerably 
longer time. The patients seldom recover complete efficiency, especially 
with regard to memory, some residue of mental deterioration remaining 
even after all physical symptoms have cleared. 


Drug psychoses 

Opium and morphine. The extent of the drug problem, other than 
that of alcohol, can be seen in the report by Moore and Gray (740). 
Of 115,845 first admission cases to mental hospitals during the period 
from 1917 to 1937 inclusive, 841 were associated with the excessive 
use of drugs. These 841 cases were distributed as follows: 43.2 per 
cent involved the use of opium derivatives; 24.7 per cent, barbiturates; 
12 per cent, bromides; 3.2 per cent, other sedatives; 1.7 per cent, anal- 
gesics; 2.2 per cent, gases; and 2.1 per cent, metals. The important 
problem in the psychoses due to drug addiction involves an under- 
standing of why the patient began to take the drug. Again we may 
find that in a number of instances the addiction to drugs is a sign of some 
deeper difficulty. Many writers have pointed to the use of drugs in 
medical treatment to relieve suffering and consequently have placed 
the blame on the physician for the production of drug psychoses. While 
it is undoubtedly true that some physicians administer drugs too freely 
and that some patients become addicted in this way, statistics appear 
to show that the large percentage of drug addicts are people of psycho- 
pathic make-up. In a great number of cases, therefore, the patient 
takes the drug because of some personal difficulty not so obvious as the 
physician's treatment with drugs. 

The physical symptoms include dryness of skin, hair, and mouth, 
loss of appetite, strongly contracted pupils, constipation alternating 
with diarrhea, impaired digestion and, in some cases, impotence and 
paresthesias. The skin may show many marks of injections if the 
drug is taken hypodermically. 

The mental symptoms are no less marked than the physical. There 
is an increasing inability to sustain the attention, memory is poor with 
considerable fabrication. The addict loses ambition, and all sense of re- 
sponsibility disappears. He becomes suspicious of all those about him 
and develops ideas of persecution. The confirmed addict will go to 
great extremes to procure the drug, frequently resorting to lying or 
stealing and even to murder. 

When the addict is deprived of the drug, there result certain character- 
istic changes which are known as the withdrawal symptoms. The pa- 
tient becomes excessively fatigued and appears ready to collapse, mus- 
cle tremors occur and the body may tremble all over. The addict is 
unable to sleep, is unusually restless and unable to concentrate. The 
effect is usually one of fear and misery frequently with horrible hallucina- 
tory experiences. He is certain that the end is near or that some terrible 


thing is about to happen to him. Since the sudden withdrawal of the 
drug proves too distressing, often resulting in complete collapse and 
sometimes proving fatal, a gradual breaking of the habit by reducing 
the dose or using substitute drugs is advocated. 

Cocaine. Although cocaine is not used as much as many of the other 
drugs, it is one of the most ruinous. It is used as a substitute for mor- 
phine in treatment or is taken in conjunction with other drugs. The 
drug in small doses is productive of a descending stimulation to the cen- 
tral nervous system, resulting in overactivity, talkativeness and restless- 
ness. Headache and dizziness usually precede the feeling of peace and 
well being during which the addict experiences pleasant, vivid halluci- 

While the abstinence symptoms are not so unpleasant as those asso- 
ciated with morphine, they include fearful hallucinations, anxiety, de- 
pression, peculiar creeping sensations under the skin (cocaine bug), 
muscular weakness, gastric disturbances and, not infrequently, delusions. 
The delusions are often persecutory in nature, having to do with jealousy 
and infidelity, and in these states the patient may be quite dangerous. 

Marijuana. Marijuana, which is taken by smoke from cigarettes or 
pipes, is not used in this country for any medicinal purpose. While 
marijuana, unlike most of the other drugs, is not complicated by with- 
drawal symptoms, specific craving or increased tolerance; nevertheless 
even mild doses result in general disturbance with flight of ideas, in- 
ability to concentrate, impulsiveness, and disorganized behavior. Defi- 
nite psychotic symptoms, including hallucinations and delusions, may 
result from the use of marijuana over a prolonged period of time. 

Miscellaneous Drugs. A number of other drugs in general use for 
medicinal purposes when injudiciously taken may result in psychotic 
symptoms. The drugs popularly referred to as the bromides and barbi- 
turates are the ones most frequently used. These drugs are often taken 
as a steadying device or as relief from insomnia. Prolonged use or 
overdosage may result in a confusion and delirium which is very much 
like other psychotic pictures. 

Gases and metals 

Psychotic symptoms are occasionally seen as a result of severe gas 
or metallic poisoning. Carbon monoxide and other gases if absorbed 
in large quantities may result in severe poisoning with loss of conscious- 
ness sometimes lasting several days. Mental symptoms including con- 
fusion, aphasia, apraxia often follow such poisoning. In many in- 
stances the patient is amnesic for the event. 


The inhalation of metallic dust or fumes from metals such as lead, 
mercury, arsenic and manganese may similarly be complicated by the 
appearance of mental symptoms. In the case of lead poisoning the 
mental changes are often so extensive as to justify the diagnosis of lead 
psychosis. Such patients show restlessness and anxiety, are sometimes 
delirious and suffer with insomnia. Hallucinations are not uncommon, 
and delusions of persecution are frequently seen. 


A variety of personality disorders are caused by infections. Micro- 
organisms such as bacteria or viruses may reach the brain and destroy 
nerve tissue. Such infections may result in disturbances of psycholog- 
ical functions of sufficient magnitude to produce a psychosis. Psychotic 
conditions are seen most frequently in syphilitic infection but other 
infections such as epidemic encephalitis and cerebrospinal meningitis 
may also be accompanied by psychotic behavior. 

Psychoses associated with syphilis 

Syphilis is a contagious venereal disease which is responsible for ap- 
proximately 10 per cent of the hospitalized nervous and mental dis- 
orders. Despite the well known disastrous results of the disease, as well 
as the clear understanding of its etiology, there is still a great need for 
a more practical approach to the problems for the control of the disorder. 

There is evidence that syphilis is, in whole or in part, responsible for 
several mental and nervous diseases. Three definite disorders stand out 
in which syphilitic infection plays the dominant role. 

Dementia paralytica or paresis. Dementia paralytica, sometimes 
termed paresis, is an organic disease of the brain of an inflammatory 
and degenerative nature, manifesting itself in progressive mental de- 
terioration and accompanied by certain definite physical signs and 
serological findings. The disorder never occurs except in persons who 
have had previous syphilitic infection. The direct cause is always the 
invasion of the brain by the treponema pallidum. Paresis usually 
does not appear until 10 or more years after the initial infection. 
The disease is more common in males than in females with the inci- 
dence peak in the fourth and fifth decades. 

An examination of the pathology of this type of mental disorder will 
clarify an understanding of it. Definite organic indications appear in 
the brain, which usually seems smaller and diminishes in weight. The 
frontal and parietal lobes are atrophied with a consequent widening of 
the sulci. The brain membranes are thickened, and there are areas of 


haemorrhagic pachymeningitis. The main pathological changes, how- 
ever, are microscopic. Many nerve cells are completely destroyed and 
the form of others distorted. There is, in addition, a marked in- 
crease of neuroglia, usually along the vessel sheaths. 

This is far from a complete explanation of the pathological changes, 
but it is sufficient to indicate that we might expect to find resulting men- 
tal disorders. 

The chief clinical signs of the disorder are motor incoordination, 
tremors, disturbances of the reflexes and convulsive seizures which may 
be epileptiform or apoplectiform in type. There is sluggishness or total 
absence of the light reflexes and inequality of the pupils. A marked 
tremor of the tongue causes characteristic speech disorders in which the 
thick, indistinct and slurred method of pronunciation may be demon- 
strated by asking the patient to pronounce such words as Methodist 
Episcopal. The handwriting shows inaccuracies comparable to those 
found in speech. There is the tremor, omission or duplication of sylla- 
bles or, in some cases, the transposition of the syllables so as to distort 
the words completely. As the motor incoordination becomes more 
marked, the writing becomes even less legible. The convulsive seizures 
so closely resemble apoplexy or epilepsy as to be taken for them, and 
after the seizure of either type, the patient is usually much worse. In 
advanced stages of the disease the patient suffers from extreme malnutri- 
tion; tremors and motor incoordination are accentuated; and the seizures 
become more frequent. 

The chief serological signs are positive Wassermann and Kahn reac- 
tions of the blood and spinal fluid, an increased number of lymphocytes 
in the spinal fluid and a typical paretic colloidal gold curve. 

Paresis usually shows three general stages: (a) prodromal, (b) fully 
developed, and (c) terminal; and three main types: (a) exalted, (b) de- 
pressed, (c) demented. It is impossible to differentiate the stages clearly 
since arrest occurs in some cases and remissions may also be present, 
but in general there is a progressive decline. 

The mental symptoms are frequently the first signs of distress that 
are noticed. There is often a complete reversal of personality traits, 
and in practically all cases the conduct of the paretic is noticed as being 
essentially different. The neat, well dressed individual becomes careless 
and slovenly; the efficient business man shows poor judgment in his 
office; the moral, upright man suddenly becomes degraded, associates 
with the most undesirable companions and becomes involved in theft, 
alcoholic bouts, etc.; the previously faithful husband and father loses 


interest in his wife and children and seems to lack ordinary thoughtful- 
ness and courtesy. 

This deterioration in the personality was well summarized by Camp- 
bell (741). 

The change in the personality which at the later stage becomes obliterated by the gros- 
ser disorders, is first shown in a loss of that special responsiveness which distinguishes the 
individual as a social unit. The responsiveness to ethical, aesthetic, intellectual, and cer- 
tain conventional standards is involved; the patient no longer shows the same judgment, 
the same sense of value, a function different from that of mere intellectual activity, and 
one upon which depends the attitude of the whole individual in the face of actual situations. 

General mental deterioration accompanies the personality alterations. 
The defect in memory is progressive, including loss of memory for remote 
as well as recent events. Important engagements are forgotten, letters 
go unanswered, judgment becomes defective. There is a disorientation, 
particularly for time, the patient frequently being unable to tell you 
where he was just a few minutes ago. He will get ready to go out to 
lunch when he has just returned or ask why his friends who have just left 
do not come to see him. One of the apparent characteristics of the dis- 
order is the inability of the patient to realize the seriousness of the illness. 
He either becomes angry when his actions are discussed or dismisses 
them as inconsequential matters. The most common type is the simple 
demented type evidencing emotional indifference and glaring memory 
defects and usually resulting in death in from two to three years. 

The exalted or expansive type described much more fully in the 
literature does not have as great incidence. Bizarre, grandiose delu- 
sions with no systematization characterize this type. The patient talks 
freely of his millions, his accomplishments, his prowess and his influence, 
describing them in the most absurd and expansive terms, but the delu- 
sions have no systematization and the patient is not carried away by 

In some cases, however, a feeling of intense depression is substituted 
for the feeling of euphoria. Melancholic delusions and hypochondri- 
acal ideas are characteristic of the depressed type. The patient complains 
that his insides are gone, his brain has become soft, his arms and legs are 
wasting away or his lungs have collapsed. One patient asked the writer 
to take an X-ray of his insides for he was certain they were gone. He 
claimed that he was no longer a human being, but existed merely as a 
spirit. During these periods of depression, suicidal attempts are not 


Cerebro-spinal syphilis. A second type of mental disorder in which 
syphilis plays an important part is cerebral or cerebro-spinal syphilis, an 
organic disease affecting the interstitial tissues of the central nervous 
system. It is caused by syphilitic infection, the symptoms showing an 
involvement of the central nervous system appearing sometimes within 
six months of the original infection and practically always within five 
years. The types are meningitis, endarteritis and gummas or soft 
tumors of syphilitic origin. 

The physical symptoms include headache, dizziness, sleeplessness, 
fainting without loss of consciousness and vomiting without a feeling of 
nausea. Practically any of the cranial nerves may be involved. Eye 
symptoms of various kinds such as blurring, dimness of vision, squint- 
ing, inequality of pupils are among the early signs. The cell count and 
globulin reaction are practically the same as in paresis, but the colloidal 
gold test shows a distinctly different form with a curve in the luetic 
rather than the paretic zone. The mental symptoms include irri- 
tability, confusion, stupor, and loss of memory, particularly for recent 

^abes dor sails with psychosis. Tabes dorsalis or locomotor ataxia is 
also of syphilitic origin. It is due to the degeneration of the posterior 
roots and neurones of the cord. A large number of the tabetic patients 
later develop general paralysis together with its mental symptoms. 

The psychosis is frequently described as an acute hallucinatory ex- 
citement. There are persecutory ideas, agitation, fearfulness, and 
auditory hallucinations. The degenerative changes in the cord lead to 
incoordination, loss of the deep reflexes and disturbances of sensation. 
A certain amount of degeneration of the cerebral cortex may be found in 
some cases, followed by cranial nerve involvement, particularly of the 
ocular and optic nerves, with the result that double vision and dimness of 
vision occur. The patient frequently reports sharp, shooting pains in 
the legs, and vomiting often occurs without nausea. The ataxia shows 
itself in the lack of precision of leg movements, particularly with the 
eyes closed. The motor coordination may be well shown by the Rom- 
berg sign and the finger to nose test. 

Encephalitis lethargica 

Psychotic symptoms are sometimes associated with inflammation of 
the brain or encephalitis. The condition is also known as epidemic 
encephalitis and is popularly referred to as sleeping sickness. The 
disorder is caused by a filterable virus which attacks the brain tissue 


as well as other organs of the body. The patients show a variety of 
symptoms accompanied by a state of lethargy. In the acute stage of 
the illness, the patients may be grouped according to definite syn- 
dromes into four types: Parkinsonian, hyperkinetic, hypersomnic-opthal- 
moplegic and psychotic types. 

The psychotic type is marked by a peculiar stupor from which the 
patient may be aroused for brief periods of good attention, only to 
slump quickly back into the stupor. In addition to the stupor the 
condition is marked by delirium, restlessness, disorientation, memory 
defects and in some instances excitement and depression. 

The organic lesions associated with the disorder are found chiefly 
in the midbrain, basal ganglia, and the posterior portion of the pons 
and the medulla, though they may also occur in the cortex, cerebellum 
and spinal cord. 

The disease is progressive and tends to spread to other parts of the 
brain. The mortality rate is high, and prognosis for complete recovery 
is unfavorable since the residual effects are widespread. 

Cerebrospinal meningitis 

The disease is caused by the microorganism diplococcus intracellu- 
laris, which enters the organism through the nasopharynx and attacks 
the meninges of the brain. Mental symptoms are almost always as- 
sociated with the disorder, but compared to other diseases the incidence 
of psychosis associated with cerebrospinal meningitis is relatively small, 
less than one per cent of all first admissions to mental hospitals in 
the United States having been so diagnosed. 

In addition to presenting a wide range of physical symptoms, the 
patients are apt to show delirium, stupor and coma with loss of ability 
to concentrate and impairment of memory. 


Acute chorea, popularly known as St. Vitus dance, has been known 
since the early part of the fifteenth century. However, despite the 
early descriptions of the disease, the nature of the offending organism 
is still unknown. It is generally assumed that the disease is due to 
an infection of the cortex and the basal ganglia in the brain, and since 
the disorder is sometimes seen with rheumatism and endocarditis, there 
appears to be some evidence that the organism responsible for chorea 
may be related to the organisms producing these diseases. Although 
adults occasionally develop chorea, the disease is primarily one of child- 


hood, aproximately four fifths of the cases developing in children 
between 5 and 15 years old. In both the childhood and adult types 
the majority of those affected are females. 

The disease is characterized primarily by the involuntary, spasmodic, 
uncoordinated and jerky movements of the muscles. In most patients 
the choretic movements are generalized, involving most of the muscles 
of the body. The muscles of the hands, face and tongue are almost 
always affected; consequently disturbances of speech are usually in 
evidence. The speech may be awkward, explosive, hasty and sometimes 
unintelligible. The choretic children are described as being sensitive, 
delinquent and disobedient, but such personality disturbances are under- 
standable in view of the uncomfortable conditions under which such 
children must live. 

The mental symptoms are most frequently restlessness, irritability, 
and emotional outbursts; but sometimes more pronounced symptoms, 
including clouding of consciousness, delirium and hallucinations, may be 
in evidence. Fortunately the prognosis is generally favorable, and 
where the home and treatment attitudes are intelligent, recurrences are 

Many other disorders, including brain abscesses and focal infections, 
show mental symptoms which may be referred to bacterial infection. 


Senile psychoses 

The psychosis of senility is one of which most individuals are some- 
what cognizant. Practically everyone has noticed the mental changes 
that take place in the aged individuals about him. Roughly speaking, 
the span of life may be divided into dozens. The first dozen years may 
be called the period of childhood; the second dozen, adolescence; the 
third and fourth, maturity; and the fifth and sixth, senescence. The 
beginning of the decay of powers is thus placed at about 48 years, though, 
of course, regressive changes begin almost as soon as maturity is reached. 
Usually, however, we refer to the years after 60 as constituting the 
senile period, but even here we must recognize the fact that heredity and 
the trials and strains of life will make for great individual differences so 
that one man's tissues may become senile long before another's. With 
the advance of age we may expect a certain degree of deterioration both 
physical and mental. The psychosis, as a rule, develops gradually and 
is characterized chiefly by impairment of retentive ability and general 


failure of memory. The memory defect, much more marked for recent 
than for remote events, causes the patient to recall events of his early life 
but to be unable to remember what happened five minutes ago. There 
is, in addition, a general reduction of mental capacity with a tendency 
toward self centering of interests. The disorientation may be accom- 
panied by depressions, irritability, paranoid trends and confused states. 
Several different clinical pictures may be drawn, but there is consider- 
able overlapping. 

Simple senile deterioration. Many of the changes seen in this clinical 
type fall well within the range of normal. The outstanding character- 
istic is the retention and memory defect, particularly the loss of mem- 
ory for recent events. The patient does considerable reminiscing, a 
condition which is probably somewhat referable to the fact that there is 
a narrowing of interest in current happenings. In fact, interest is so 
closely restricted that the aftairs of the members of the immediate fam- 
ily are often of no concern whatever to the patient, who displays careful 
attention only to his own personal wants. Accompanying this limita- 
tion of interest is a considerable reduction in mental capacity which 
reveals itself particularly in the lack of ability to concentrate on or even 
to attend to present happenings, a condition which, in a sense, would 
explain a failure to display interest. A certain degree of irritability ap- 
pears inevitably, particularly at night. 

Presbyophrenic type. The general picture of presbyophrenia resem- 
bles somewhat Korsakow's disease, with retention defect and much con- 
fabulation. The disorder usually begins earlier than simple senile psy- 
chosis and frequently shows complete disorientation. Unlike the simple 
senile type the presbyophrenic appears mentally alert and able to 
grasp the present situation, but he is entirely unable to understand his 
own relationship to the situation. His forgetfulness leads to absurd 
fabrications and contradictions, and he shows great restlessness which 
prevents him from completing any task. 

Other types are classified as: delirious and confused types; depressed 
and agitated types; or paranoid types, depending upon the principal 
content of the picture. In addition to these types, there are other 
senile psychoses such as Alzheimer's and Pick's disease, but they are 
less frequently seen. 

Psychoses with cerebral arteriosclerosis 

Cerebral arteriosclerosis occurs usually in people about 50 years of 
age, though it is sometimes found considerably earlier. The disease 


is caused by the sclerosis of the arterial blood vessels. Often it is 
difficult to distinguish from a senile psychosis, particularly if the disease 
occurs in the senile period. However, in addition to the fact that the 
onset is usually earlier in cerebral arteriosclerosis, insight is more fre- 
quently present and intellectual impairment not as pronounced as in 
the senile psychosis. A psychosis does not always accompany the 
disease, although definite mental symptoms usually are present. 

The disorder may be ushered in with an apoplectic or epileptic seizure. 
The individual then loses the ability to concentrate or to fix the atten- 
tion and suffers from a realization of his decreased efficiency. An 
impairment of memory which progresses from recent to remote events 
follows. Often there is marked emotional instability resulting in alter- 
nate weeping and laughing without sufficient cause, emotional out- 
bursts, or great irritability. In addition, there are states of cloudiness 
of consciousness, confused states, depressions, suspicions and occasion- 
ally paranoid trends. 

The cause of the sclerosis which is responsible for the symptoms is 
not well known. Insufficient rest, inadequate relaxation, worry and 
anxiety are generally believed to be contributory factors. Pollock (742) 
has taken the position that syphilis and alcohol are also important 
contributory factors to the development of the disorder. An excellent 
summation of the senile and arteriosclerotic syndromes has been pre- 
sented in a volume edited by Kaplan (743) entitled, Mental Disorders 
in Later Life. 


The diagnosis of traumatic psychoses is restricted to psychotic disturb- 
ances following injury to the head. The fact is, of course, recognized 
that mental disorders may occur subsequent to physical injuries of any 
nature, but the term traumatic is applied only to the psychic disorders 
which occur as a direct result of the injury. In all cases the direct con- 
nection between the brain injury and the psychotic symptoms cannot be 
shown so that in these instances the use of the term traumatic psychoses 
is obviously based upon an assumption. 

It should also be noted that in a large percentage of the cases other 
etiological factors such as alcoholism, syphilis and psychopathic traits 
are to be found. This rare disorder constitutes not more than from 0.3 
to 0.5 per cent of the first admissions to mental hospitals of this country. 
In some cases there is a traumatic delirium resembling the Korsakow 
mental syndrome. Others are characterized by a gradual post-traumatic 


change in disposition. The patient becomes easily fatigued, unduly 
irritable, suffers from headache and vasomotor instability. This type is 
usually referred to as post-traumatic constitution, and frequently para- 
noid tendencies are evidenced, while in other cases the picture resembles 
more closely epilepsy or hysteria. A third type, usually referred to as 
post-traumatic mental enfeeblement, while evidencing little real mental 
disturbance, leaves the individual at a lower mental level for the rest of 
his life. He no longer appears to have the same judgment or organizing 
ability and may never be so alert mentally as formerly. 


The importance of disorders of the endocrine system in the under- 
standing of mental diseases is being given an increasing amount of at- 
tention by modern investigators. The secretions from the endocrine 
glands are known to have a far reaching effect on behavior and are re- 
ferred to as determinants of both physical and mental activity. Unfor- 
tunately, due to the complexity of the glandular system, and the tend- 
ency for the secretions from one gland to influence many of the others, 
the knowledge of the exact functioning of the glands is limited. The 
fact that the glandular secretions are intimately related to conscious be- 
havior and therefore play an important role in the understanding of 
psychological reactions has been repeatedly shown. The relation of 
glandular secretions to such experiences as elation, depression, anger, 
fear, excitability, calm, etc. is well known and we should therefore expect 
that the dysfunctioning of these glands would in some instances be re- 
sponsible for peculiar or unusual behavior patterns. These glands are 
intimately related to the activity or are infl